Raw X12 — CIN UN91009K

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0712*|*00501*518753713*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0712*753713*X*005010X279A1~ST*270*3713*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*UN91009K~EQ*30~DTP*291*D8*20260812~SE*13*3713~GE*1*753713~IEA*1*518753713~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0312*^*00501*171724030*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031229*171724030*X*005010X279A1~ST*271*171724030*005010X279A1~BHT*0022*11*202608120712000001*20260812*031229~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*MAKSIMENKO*NINA*F***MI*UN91009K~N3*26       CASS PL              6E~N4*BROOKLYN*NY*11235~DMG*D8*19501012*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=01~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*UN91009K~LS*2120~NM1*P4*2*LOCAL 1199 SEIU HC*****PI*LOHC~N3*PO BOX 1007 TIMES SQUARE STATION~N4*NEW YORK*NY*101081007~PER*IC*PROVIDER SERVICES*TE*6464739200~LE*2120~EB*R*IND*30~REF*6P*H3312~LS*2120~NM1*P4*2*AETNA MEDICARE*****PI*H3312~N3*151 FARMINGTON AVENUE~N4*HARTFORD*CT*06156~PER*IC*PROVIDER SERVICES*TE*8002825366~LE*2120~EB*R*IND*30~REF*18*6AA1VJ4YY90~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*52*171724030~GE*1*171724030~IEA*1*171724030~