Raw X12 — CIN RN26611V

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0706*|*00501*518410608*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0706*410608*X*005010X279A1~ST*270*0608*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*RN26611V~EQ*30~DTP*291*D8*20260812~SE*13*0608~GE*1*410608~IEA*1*518410608~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0306*^*00501*167481530*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030646*167481530*X*005010X279A1~ST*271*167481530*005010X279A1~BHT*0022*11*202608120706000001*20260812*030646~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*CIPRIANO*SANDRA*I***MI*RN26611V~N3*95-40    112TH STREET~N4*S RICHMOND HILL*NY*11419~DMG*D8*19641220*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260501~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=03~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*1T40UU5UH38~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*36*167481530~GE*1*167481530~IEA*1*167481530~