Raw X12 — CIN WH16839U

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1955*|*00501*305316106*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1955*316106*X*005010X279A1~ST*270*6106*005010X279A1~BHT*0022*13*202608091955000001*20260809*1955~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*202608091955000001*00000000ND~NM1*IL*1******MI*WH16839U~EQ*30~DTP*291*D8*20260806~SE*13*6106~GE*1*316106~IEA*1*305316106~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1555*^*00501*315080430*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*155511*315080430*X*005010X279A1~ST*271*315080430*005010X279A1~BHT*0022*11*202608091955000001*20260809*155511~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*202608091955000001*00000000ND~NM1*IL*1*ROZOVA*RIVA****MI*WH16839U~N3*2424 CROPSEY AVE              14D~N4*BROOKLYN*NY*11214~DMG*D8*19280513*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20251101~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 538~LS*2120~NM1*Y2*2*VNS CHOICE PARTIAL LTC*****PI*VC~N3*220 E 42ND ST FL 6~N4*NEW YORK*NY*100175831~PER*IC*PROVIDER SERVICES*TE*8667830222~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*1*IND*88~EB*R*IND*30~REF*18*6CW6YR2NY74~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*35*315080430~GE*1*315080430~IEA*1*315080430~