Raw X12 — CIN UG88844V

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260914*1120*|*00501*384851061*1*P*:~GS*HS*00ND*EMEDNYREL*20260914*1120*851061*X*005010X279A1~ST*270*1061*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*UG88844V~EQ*30~DTP*291*D8*20260914~SE*13*1061~GE*1*851061~IEA*1*384851061~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260914*0720*^*00501*245169730*0*P*|~GS*HB*EMEDNYREL*00ND*20260914*072051*245169730*X*005010X279A1~ST*271*245169730*005010X279A1~BHT*0022*11*202609141120000001*20260914*072051~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*POSLEDNIK*STANISLAWA*E***MI*UG88844V~N3*53135    63 RD~N4*MASPETH*NY*11378~DMG*D8*19450812*F~DTP*472*D8*20260914~DTP*346*D8*20260901~DTP*102*D8*20251201~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~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*H3312~LS*2120~NM1*P4*2*AETNA MEDICARE*****PI*H3312~N3*151 FARMINGTON AVENUE~N4*HARTFORD*CT*06156~PER*IC*PROVIDER SERVICES*TE*8002825366~LE*2120~EB*R*IND*30~REF*18*3MK7HP8PC38~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*43*245169730~GE*1*245169730~IEA*1*245169730~