Raw X12 — CIN RA75761Y

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1951*|*00501*564291853*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1951*291853*X*005010X279A1~ST*270*1853*005010X279A1~BHT*0022*13*202608121951000001*20260812*1951~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*202608121951000001*00000000ND~NM1*IL*1******MI*RA75761Y~EQ*30~DTP*291*D8*20260813~SE*13*1853~GE*1*291853~IEA*1*564291853~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1551*^*00501*528784330*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155127*528784330*X*005010X279A1~ST*271*528784330*005010X279A1~BHT*0022*11*202608121951000001*20260812*155127~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*202608121951000001*00000000ND~NM1*IL*1*AGUSTINIANO*MARIA****MI*RA75761Y~N3*1233 117TH STREET~N4*COLLEGE POINT*NY*11356~DMG*D8*19380517*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=06~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~SE*31*528784330~GE*1*528784330~IEA*1*528784330~