Raw X12 — CIN XA75303V

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0705*|*00501*518326269*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0705*326269*X*005010X279A1~ST*270*6269*005010X279A1~BHT*0022*13*202608120705000001*20260812*0705~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*202608120705000001*00000000ND~NM1*IL*1******MI*XA75303V~EQ*30~DTP*291*D8*20260812~SE*13*6269~GE*1*326269~IEA*1*518326269~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0305*^*00501*167100430*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030521*167100430*X*005010X279A1~ST*271*167100430*005010X279A1~BHT*0022*11*202608120705000001*20260812*030521~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*202608120705000001*00000000ND~NM1*IL*1*BAIGULOVA*TAYA****MI*XA75303V~N3*2950 W 31ST ST                06F~N4*BROOKLYN*NY*11224~DMG*D8*19530901*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~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*8AC5XD1DV85~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*35*167100430~GE*1*167100430~IEA*1*167100430~