Raw X12 — CIN XM86022S

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1958*|*00501*305503061*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1958*503061*X*005010X279A1~ST*270*3061*005010X279A1~BHT*0022*13*202608091958000001*20260809*1958~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*202608091958000001*00000000ND~NM1*IL*1******MI*XM86022S~EQ*30~DTP*291*D8*20260806~SE*13*3061~GE*1*503061~IEA*1*305503061~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1558*^*00501*315205130*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*155818*315205130*X*005010X279A1~ST*271*315205130*005010X279A1~BHT*0022*11*202608091958000001*20260809*155818~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*202608091958000001*00000000ND~NM1*IL*1*YAKOBSON*RIMMA****MI*XM86022S~N3*1170     PENNSYLVANIA AVE     9H~N4*BROOKLYN*NY*11239~DMG*D8*19441006*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260701~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=12~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*2PN0WC6VW36~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*44*315205130~GE*1*315205130~IEA*1*315205130~