Raw X12 — CIN SF32417N

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1953*|*00501*564404389*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1953*404389*X*005010X279A1~ST*270*4389*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*SF32417N~EQ*30~DTP*291*D8*20260813~SE*13*4389~GE*1*404389~IEA*1*564404389~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1553*^*00501*529306330*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155320*529306330*X*005010X279A1~ST*271*529306330*005010X279A1~BHT*0022*11*202608121953000001*20260812*155320~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*CASTRO*DIANA*L***MI*SF32417N~N3*528 WEST 111 STREET           74~N4*NEW YORK*NY*10025~DMG*D8*19390901*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260301~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=04~LS*2120~NM1*Y2*2*VILLAGE SENIOR SERVICES CORP MAP*****PI*VM~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*R*IND*30~REF*18*ZYJ008W02561~REF*6P*1744851152~LS*2120~NM1*P4*2*ANTHEM BC/BS (EMPIRE)*****PI*12~N3*PO BOX 1407 CHURCH ST STATION*ATTN  CLAIMS DEPT~N4*NEW YORK*NY*100081407~PER*IC*PROVIDER SERVICES*TE*8005235978~LE*2120~EB*R*IND*30~REF*6P*H2168~LS*2120~NM1*P4*2*VILLAGECAREMAX MEDICARE TOTAL ADVAN*****PI*H2168~N3*P O  BOX 5426~N4*HAUPPAUGE*NY*117885426~PER*IC*PROVIDER SERVICES*TE*8004696292~LE*2120~EB*R*IND*30~REF*18*5JA5N25YM70~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*53*529306330~GE*1*529306330~IEA*1*529306330~