Raw X12 — CIN YE43799E

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1954*|*00501*305282808*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1954*282808*X*005010X279A1~ST*270*2808*005010X279A1~BHT*0022*13*202608091954000001*20260809*1954~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*202608091954000001*00000000ND~NM1*IL*1******MI*YE43799E~EQ*30~DTP*291*D8*20260806~SE*13*2808~GE*1*282808~IEA*1*305282808~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1554*^*00501*315062630*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*155438*315062630*X*005010X279A1~ST*271*315062630*005010X279A1~BHT*0022*11*202608091954000001*20260809*155438~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*202608091954000001*00000000ND~NM1*IL*1*RAMOS*RAMONA****MI*YE43799E~N3*1629 WALTON AVE               D1~N4*BRONX*NY*10452~DMG*D8*19521111*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 508~MSG*RECERT MONTH=06~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*18*111707765~LS*2120~NM1*P4*2*OTHER INSURANCE*****PI*05~N3*OTHER INSURANCE~N4*CALL LOCAL DSS*NY*12345~LE*2120~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*1NH9M44XP26~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*51*315062630~GE*1*315062630~IEA*1*315062630~