Raw X12 — CIN VP87508R

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1957*|*00501*305432254*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1957*432254*X*005010X279A1~ST*270*2254*005010X279A1~BHT*0022*13*202608091957000001*20260809*1957~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*202608091957000001*00000000ND~NM1*IL*1******MI*VP87508R~EQ*30~DTP*291*D8*20260806~SE*13*2254~GE*1*432254~IEA*1*305432254~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1557*^*00501*315160730*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*155707*315160730*X*005010X279A1~ST*271*315160730*005010X279A1~BHT*0022*11*202608091957000001*20260809*155707~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*202608091957000001*00000000ND~NM1*IL*1*TINEO*CRISTINA****MI*VP87508R~N3*7320 71ST PLACE               1~N4*GLENDALE*NY*11385~DMG*D8*19511205*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260501~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~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*H3387~LS*2120~NM1*P4*2*UNITEDHEALTHCARE DUAL COMPLETE*****PI*H3387~N3*P O BOX 917~N4*NEW YORK*NY*10269~PER*IC*PROVIDER SERVICES*TE*8005144912~LE*2120~EB*R*IND*30~REF*18*8XY1UE7VY37~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*315160730~GE*1*315160730~IEA*1*315160730~