Raw X12 — CIN NK77128J

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0712*|*00501*518728748*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0712*728748*X*005010X279A1~ST*270*8748*005010X279A1~BHT*0022*13*202608120712000001*20260812*0712~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*202608120712000001*00000000ND~NM1*IL*1******MI*NK77128J~EQ*30~DTP*291*D8*20260812~SE*13*8748~GE*1*728748~IEA*1*518728748~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0312*^*00501*170998730*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031204*170998730*X*005010X279A1~ST*271*170998730*005010X279A1~BHT*0022*11*202608120712000001*20260812*031204~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*202608120712000001*00000000ND~NM1*IL*1*LEYNIK*ZOYA****MI*NK77128J~N3*557 AVENUE Z                  2C~N4*BROOKLYN*NY*11223~DMG*D8*19451122*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260301~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~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*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*3H49VM6YU10~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*45*170998730~GE*1*170998730~IEA*1*170998730~