Raw X12 — CIN QP99342E

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0712*|*00501*518729687*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0712*729687*X*005010X279A1~ST*270*9687*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*QP99342E~EQ*30~DTP*291*D8*20260812~SE*13*9687~GE*1*729687~IEA*1*518729687~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0312*^*00501*171099230*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031205*171099230*X*005010X279A1~ST*271*171099230*005010X279A1~BHT*0022*11*202608120712000001*20260812*031205~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*LIBERMAN*DINA****MI*QP99342E~N3*3152 BRIGHTON 6TH ST          417~N4*BROOKLYN*NY*11235~DMG*D8*19450609*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260701~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 508~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*R*IND*30~REF*18*8QM3KM5QH14~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*36*171099230~GE*1*171099230~IEA*1*171099230~