Raw X12 — CIN VD21868C

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1022*|*00501*357364772*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1022*364772*X*005010X279A1~ST*270*4772*005010X279A1~BHT*0022*13*202608101022000001*20260810*1022~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*202608101022000001*00000000ND~NM1*IL*1******MI*VD21868C~EQ*30~DTP*291*D8*20260806~SE*13*4772~GE*1*364772~IEA*1*357364772~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0622*^*00501*237257830*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*062240*237257830*X*005010X279A1~ST*271*237257830*005010X279A1~BHT*0022*11*202608101022000001*20260810*062240~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*202608101022000001*00000000ND~NM1*IL*1*BEZNIS*VALERIY****MI*VD21868C~N3*40-60    ELBERTSON STREET     3A~N4*ELMHURST*NY*11373~DMG*D8*19510406*M~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20260301~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=09~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*1K76YJ4HV82~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*35*237257830~GE*1*237257830~IEA*1*237257830~