Raw X12 — CIN WZ02010C

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0706*|*00501*518405309*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0706*405309*X*005010X279A1~ST*270*5309*005010X279A1~BHT*0022*13*202608120706000001*20260812*0706~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*202608120706000001*00000000ND~NM1*IL*1******MI*WZ02010C~EQ*30~DTP*291*D8*20260812~SE*13*5309~GE*1*405309~IEA*1*518405309~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0306*^*00501*167476930*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030640*167476930*X*005010X279A1~ST*271*167476930*005010X279A1~BHT*0022*11*202608120706000001*20260812*030640~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*202608120706000001*00000000ND~NM1*IL*1*CHMIELOWIEC*JACEK****MI*WZ02010C~N3*6532 78TH STREET~N4*MIDDLE VILLAGE*NY*11379~DMG*D8*19750628*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*89~MSG*S1~MSG*CNTY CD=66 508~MSG*RECERT MONTH=07~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*2HG7K46MW71~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*38*167476930~GE*1*167476930~IEA*1*167476930~