Raw X12 — CIN XV70077S

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1953*|*00501*305203728*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1953*203728*X*005010X279A1~ST*270*3728*005010X279A1~BHT*0022*13*202608091953000001*20260809*1953~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*202608091953000001*00000000ND~NM1*IL*1******MI*XV70077S~EQ*30~DTP*291*D8*20260806~SE*13*3728~GE*1*203728~IEA*1*305203728~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1553*^*00501*315005430*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*155319*315005430*X*005010X279A1~ST*271*315005430*005010X279A1~BHT*0022*11*202608091953000001*20260809*155319~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*202608091953000001*00000000ND~NM1*IL*1*ORTIZ*ESTHER****MI*XV70077S~N3*12       WEST 101TH ST        13~N4*NEW YORK*NY*10025~DMG*D8*19351115*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260701~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=01~LS*2120~NM1*Y2*2*VILLAGE SENIOR SVC CORP PARTIAL LTC*****PI*VL~N3*112 CHARLES ST FL 2~N4*NEW YORK*NY*100142653~PER*IC*PROVIDER SERVICES*TE*8557692500~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*1*IND*88~EB*R*IND*30~REF*6P*H3359~LS*2120~NM1*P4*2*HEALTHFIRST MEDICARE PLAN*****PI*H3359~N3*HEALTHFIRST MEDICARE PLAN  PO BOX 5165~N4*NEW YORK*NY*10274~PER*IC*PROVIDER SERVICES*TE*8882601010~LE*2120~EB*R*IND*30~REF*18*112538331~REF*6P*HFPP01~LS*2120~NM1*P4*2*DAVIS VISION*****PI*90~N3*PO BOX 1501~N4*LATHAM*NY*121108001~PER*IC*PROVIDER SERVICES*TE*8009995431~LE*2120~EB*R*IND*30~REF*18*6CV5AX1FT59~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*52*315005430~GE*1*315005430~IEA*1*315005430~