Raw X12 — CIN PK35180K

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260914*1120*|*00501*384844479*1*P*:~GS*HS*00ND*EMEDNYREL*20260914*1120*844479*X*005010X279A1~ST*270*4479*005010X279A1~BHT*0022*13*202609141120000001*20260914*1120~HL*1**20*1~NM1*PR*2*NYSDOH*****PI*EMEDNY~HL*2*1*21*1~NM1*1P*2*MEDICAID PLANNING GROUP CORP*****SV*08046628~PRV*PE*PXC*251B00000X~HL*3*2*22*0~TRN*1*202609141120000001*00000000ND~NM1*IL*1******MI*PK35180K~EQ*30~DTP*291*D8*20260914~SE*13*4479~GE*1*844479~IEA*1*384844479~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260914*0720*^*00501*244960530*0*P*|~GS*HB*EMEDNYREL*00ND*20260914*072044*244960530*X*005010X279A1~ST*271*244960530*005010X279A1~BHT*0022*11*202609141120000001*20260914*072044~HL*1**20*1~NM1*PR*2*NYSDOH*****FI*141797357~PER*IC*EMEDNY PROVIDER SERVICES*TE*8003439000*UR*www.emedny.org~HL*2*1*21*1~NM1*1P*2*MEDICAID PLANNING GROUP CORP*****SV*08046628~HL*3*2*22*0~TRN*2*202609141120000001*00000000ND~NM1*IL*1*USMANOV*SHUHRAT****MI*PK35180K~N3*3145 BRIGHTON 4TH STREET      509~N4*BROOKLYN*NY*11235~DMG*D8*19520914*M~DTP*472*D8*20260914~DTP*346*D8*20260901~DTP*102*D8*20251201~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=10~LS*2120~NM1*Y2*2*ELDERSERVE HEALTH INC MLTCP*****PI*EH~N3*80 W 225TH ST FL 3~N4*BRONX*NY*104637002~PER*IC*PROVIDER SERVICES*TE*8003703600~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*1*IND*88~EB*R*IND*30~REF*6P*H5599~LS*2120~NM1*P4*2*WELLCARE FIDELIS DUAL ACCESS*****PI*H5599~N3*25-01 JACKSON AVE~N4*LONG ISLAND CITY*NY*11101~PER*IC*PROVIDER SERVICES*TE*8883433547~LE*2120~EB*R*IND*30~REF*18*7C23JR8PT95~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*244960530~GE*1*244960530~IEA*1*244960530~