Raw X12 — CIN KS26472B

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0705*|*00501*518350487*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0705*350487*X*005010X279A1~ST*270*0487*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*KS26472B~EQ*30~DTP*291*D8*20260812~SE*13*0487~GE*1*350487~IEA*1*518350487~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0305*^*00501*167424930*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030546*167424930*X*005010X279A1~ST*271*167424930*005010X279A1~BHT*0022*11*202608120705000001*20260812*030546~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*BLAIR*DOROTHY*L***MI*KS26472B~N3*630 ROCKAWAY AVENUE~N4*BROOKLYN*NY*11212~DMG*D8*19391215*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260201~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*PD~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=12~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*W*IND*CQ~LS*2120~NM1*Y2*2*METRO CARE MANAGEMENT LLC*****XX*1922565118~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*SRH CHN LEAD HEALTH HOME LLC*****XX*1750053948~LE*2120~EB*R*IND*30~REF*18*U1247015401~REF*6P*3213960~LS*2120~NM1*P4*2*CIGNA DENTAL*****PI*CDNT~N3*PO BOX 188037~N4*CHATTANOOGA*TN*374228037~PER*IC*PROVIDER SERVICES*TE*8002446224~LE*2120~EB*R*IND*30~REF*18*YLA930244557~REF*6P*157157~LS*2120~NM1*P4*2*ANTHEM BC/BS (EMPIRE)*****PI*12~N3*PO BOX 1407 CHURCH ST STATION*ATTN  CLAIMS DEPT~N4*NEW YORK*NY*100081407~PER*IC*PROVIDER SERVICES*TE*8005235978~LE*2120~EB*R*IND*30~REF*18*8KG3NJ2MP85~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*65*167424930~GE*1*167424930~IEA*1*167424930~