Raw X12 — CIN XE61902W

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1953*|*00501*564388952*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1953*388952*X*005010X279A1~ST*270*8952*005010X279A1~BHT*0022*13*202608121953000001*20260812*1953~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*202608121953000001*00000000ND~NM1*IL*1******MI*XE61902W~EQ*30~DTP*291*D8*20260813~SE*13*8952~GE*1*388952~IEA*1*564388952~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1553*^*00501*529247530*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155304*529247530*X*005010X279A1~ST*271*529247530*005010X279A1~BHT*0022*11*202608121953000001*20260812*155304~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*202608121953000001*00000000ND~NM1*IL*1*CANNON*WILLIAM*A***MI*XE61902W~N3*102 CUMBERLAND WALK~N4*BROOKLYN*NY*11205~DMG*D8*19550417*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260401~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~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*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*6CU1WQ7KX12~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*44*529247530~GE*1*529247530~IEA*1*529247530~