Raw X12 — CIN WP13615H

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0708*|*00501*518536470*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0708*536470*X*005010X279A1~ST*270*6470*005010X279A1~BHT*0022*13*202608120708000001*20260812*0708~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*202608120708000001*00000000ND~NM1*IL*1******MI*WP13615H~EQ*30~DTP*291*D8*20260812~SE*13*6470~GE*1*536470~IEA*1*518536470~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0308*^*00501*167598030*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030852*167598030*X*005010X279A1~ST*271*167598030*005010X279A1~BHT*0022*11*202608120708000001*20260812*030852~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*202608120708000001*00000000ND~NM1*IL*1*GOYZIN*SOFIYA****MI*WP13615H~N3*1159 BRIGHTON BCH AVE         6H~N4*BROOKLYN*NY*11235~DMG*D8*19461109*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260401~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~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*4GG1GQ5FC25~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*35*167598030~GE*1*167598030~IEA*1*167598030~