Raw X12 — CIN WH16839U

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1032*|*00501*357964452*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1032*964452*X*005010X279A1~ST*270*4452*005010X279A1~BHT*0022*13*202608101032000001*20260810*1032~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*202608101032000001*00000000ND~NM1*IL*1******MI*WH16839U~EQ*30~DTP*291*D8*20260806~SE*13*4452~GE*1*964452~IEA*1*357964452~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0632*^*00501*238170030*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*063240*238170030*X*005010X279A1~ST*271*238170030*005010X279A1~BHT*0022*11*202608101032000001*20260810*063240~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*202608101032000001*00000000ND~NM1*IL*1*ROZOVA*RIVA****MI*WH16839U~N3*2424 CROPSEY AVE              14D~N4*BROOKLYN*NY*11214~DMG*D8*19280513*F~DTP*472*D8*20260810~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*238170030~GE*1*238170030~IEA*1*238170030~