Raw X12 — CIN ZT93994A

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0709*|*00501*518572803*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0709*572803*X*005010X279A1~ST*270*2803*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*ZT93994A~EQ*30~DTP*291*D8*20260812~SE*13*2803~GE*1*572803~IEA*1*518572803~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0309*^*00501*167632730*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030928*167632730*X*005010X279A1~ST*271*167632730*005010X279A1~BHT*0022*11*202608120709000001*20260812*030928~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*HUDSON*NATHANIEL****MI*ZT93994A~N3*2970     WEST   27 STREET     2403~N4*BROOKLYN*NY*11224~DMG*D8*19811025*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~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*W*IND*CQ~LS*2120~NM1*Y2*2*JEMCARE LLC*****XX*1265926216~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*COMMUNITY CARE MANAGEMENT PARTNERS*****XX*1366780850~LE*2120~EB*R*IND*30~REF*18*00000011521~REF*6P*ICA001~LS*2120~NM1*P4*2*DAVIS VISION*****PI*90~N3*PO BOX 1501~N4*LATHAM*NY*121108001~PER*IC*PROVIDER SERVICES*TE*8009995431~LE*2120~EB*R*IND*30~REF*18*6RH5KT0NY93~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*55*167632730~GE*1*167632730~IEA*1*167632730~