Raw X12 — CIN XA90852Z

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*2005*|*00501*305957672*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*2005*957672*X*005010X279A1~ST*270*7672*005010X279A1~BHT*0022*13*202608092005000001*20260809*2005~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*202608092005000001*00000000ND~NM1*IL*1******MI*XA90852Z~EQ*30~DTP*291*D8*20260806~SE*13*7672~GE*1*957672~IEA*1*305957672~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1605*^*00501*316659530*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*160553*316659530*X*005010X279A1~ST*271*316659530*005010X279A1~BHT*0022*11*202608092005000001*20260809*160553~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*202608092005000001*00000000ND~NM1*IL*1*KOROLOVA*NADIIA****MI*XA90852Z~N3*135      BEACH 19 STREET      3F~N4*FAR ROCKAWAY*NY*11691~DMG*D8*19511019*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260801~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=01~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~SE*30*316659530~GE*1*316659530~IEA*1*316659530~