Raw X12 — CIN XH63924Q

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1037*|*00501*358275756*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1037*275756*X*005010X279A1~ST*270*5756*005010X279A1~BHT*0022*13*202608101037000001*20260810*1037~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*202608101037000001*00000000ND~NM1*IL*1******MI*XH63924Q~EQ*30~DTP*291*D8*20260806~SE*13*5756~GE*1*275756~IEA*1*358275756~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0637*^*00501*238493530*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*063751*238493530*X*005010X279A1~ST*271*238493530*005010X279A1~BHT*0022*11*202608101037000001*20260810*063751~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*202608101037000001*00000000ND~NM1*IL*1*TARIKOVA*YEVA****MI*XH63924Q~N3*577      AVENUE Z             1A~N4*BROOKLYN*NY*11223~DMG*D8*19460602*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=08~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*18*5KQ9JR9XQ53~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*37*238493530~GE*1*238493530~IEA*1*238493530~