Raw X12 — CIN YY04685R

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1952*|*00501*564365928*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1952*365928*X*005010X279A1~ST*270*5928*005010X279A1~BHT*0022*13*202608121952000001*20260812*1952~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*202608121952000001*00000000ND~NM1*IL*1******MI*YY04685R~EQ*30~DTP*291*D8*20260813~SE*13*5928~GE*1*365928~IEA*1*564365928~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1552*^*00501*529162030*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155241*529162030*X*005010X279A1~ST*271*529162030*005010X279A1~BHT*0022*11*202608121952000001*20260812*155241~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*202608121952000001*00000000ND~NM1*IL*1*BRYANT*JASPER*R***MI*YY04685R~N3*395 LEXINGTON AVE             2 D~N4*BROOKLYN*NY*11216~DMG*D8*19580612*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~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*R*IND*30~REF*18*9NJ9FD0FQ20~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*34*529162030~GE*1*529162030~IEA*1*529162030~