Raw X12 — CIN VD78060U

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0709*|*00501*518564501*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0709*564501*X*005010X279A1~ST*270*4501*005010X279A1~BHT*0022*13*202608120709000001*20260812*0709~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*202608120709000001*00000000ND~NM1*IL*1******MI*VD78060U~EQ*30~DTP*291*D8*20260812~SE*13*4501~GE*1*564501~IEA*1*518564501~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0309*^*00501*167624930*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030920*167624930*X*005010X279A1~ST*271*167624930*005010X279A1~BHT*0022*11*202608120709000001*20260812*030920~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*202608120709000001*00000000ND~NM1*IL*1*HERRERA*GISELA****MI*VD78060U~N3*661      EUCLID AVENUE        2~N4*BROOKLYN*NY*11208~DMG*D8*19530807*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~MSG*RECERT MONTH=10~LS*2120~NM1*Y2*2*VNS CHOICE PARTIAL LTC*****PI*VC~N3*220 E 42ND ST FL 6~N4*NEW YORK*NY*100175831~PER*IC*PROVIDER SERVICES*TE*8667830222~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*1*IND*88~EB*R*IND*30~REF*6P*H4868~LS*2120~NM1*P4*2*WELLCARE*****PI*H4868~N3*PO BOX 25885~N4*TAMPA*FL*33622~PER*IC*PROVIDER SERVICES*TE*8002785155~LE*2120~EB*R*IND*30~REF*18*2Q46RY5PY62~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*44*167624930~GE*1*167624930~IEA*1*167624930~