Raw X12 — CIN VU13122V

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0705*|*00501*518359252*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0705*359252*X*005010X279A1~ST*270*9252*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*VU13122V~EQ*30~DTP*291*D8*20260812~SE*13*9252~GE*1*359252~IEA*1*518359252~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0305*^*00501*167434330*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030554*167434330*X*005010X279A1~ST*271*167434330*005010X279A1~BHT*0022*11*202608120705000001*20260812*030554~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*BORONENKO*TATYANA****MI*VU13122V~N3*500      BRIGHTWATER CT       14B~N4*BROOKLYN*NY*11235~DMG*D8*19440912*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20251001~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=05~LS*2120~NM1*Y2*2*ELDERSERVE HEALTH INC MLTCP*****PI*EH~N3*80 W 225TH ST FL 3~N4*BRONX*NY*104637002~PER*IC*PROVIDER SERVICES*TE*8003703600~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*1*IND*88~EB*R*IND*30~REF*6P*H5549~LS*2120~NM1*P4*2*VNS CHOICE MEDICARE*****PI*H5549~N3*1250 BROADWAY  3RD FLOOR~N4*NEW YORK*NY*10001~PER*IC*PROVIDER SERVICES*TE*8665976674~LE*2120~EB*R*IND*30~REF*18*1JY8G05XT52~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*167434330~GE*1*167434330~IEA*1*167434330~