Raw X12 — CIN RR91701A

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0707*|*00501*518436342*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0707*436342*X*005010X279A1~ST*270*6342*005010X279A1~BHT*0022*13*202608120707000001*20260812*0707~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*202608120707000001*00000000ND~NM1*IL*1******MI*RR91701A~EQ*30~DTP*291*D8*20260812~SE*13*6342~GE*1*436342~IEA*1*518436342~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0307*^*00501*167505230*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030711*167505230*X*005010X279A1~ST*271*167505230*005010X279A1~BHT*0022*11*202608120707000001*20260812*030711~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*202608120707000001*00000000ND~NM1*IL*1*DUBRAVIN*YAKOV****MI*RR91701A~N3*8855 BAY PKWY                 8H~N4*BROOKLYN*NY*11214~DMG*D8*19390707*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*CNTY CD=66 5H9~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*8DY1M87VA90~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*34*167505230~GE*1*167505230~IEA*1*167505230~