Raw X12 — CIN XQ69205K

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0709*|*00501*518574535*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0709*574535*X*005010X279A1~ST*270*4535*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*XQ69205K~EQ*30~DTP*291*D8*20260812~SE*13*4535~GE*1*574535~IEA*1*518574535~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0309*^*00501*167634130*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030930*167634130*X*005010X279A1~ST*271*167634130*005010X279A1~BHT*0022*11*202608120709000001*20260812*030930~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*HUNTE*ALVIN*N***MI*XQ69205K~N3*375 BLAKE AVE                 6G~N4*BROOKLYN*NY*11212~DMG*D8*19740928*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~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*W*IND*CQ~LS*2120~NM1*Y2*2*INSTITUTE FOR COMMUNITY LIVING*****XX*1164549812~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*COORDINATED BEHAVIORAL CARE INC*****XX*1730451071~LE*2120~EB*R*IND*30~REF*6P*H0423~LS*2120~NM1*P4*2*METROPLUS HEALTH PLAN, INC.*****PI*H0423~N3*160 WATER STREET~N4*NEW YORK*NY*10038~PER*IC*PROVIDER SERVICES*TE*8669860356~LE*2120~EB*R*IND*30~REF*18*3W58M65RK52~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*52*167634130~GE*1*167634130~IEA*1*167634130~