Raw X12 — CIN QZ38606T

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1953*|*00501*564421990*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1953*421990*X*005010X279A1~ST*270*1990*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*QZ38606T~EQ*30~DTP*291*D8*20260813~SE*13*1990~GE*1*421990~IEA*1*564421990~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1553*^*00501*529373130*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155337*529373130*X*005010X279A1~ST*271*529373130*005010X279A1~BHT*0022*11*202608121953000001*20260812*155337~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*CLANTON*LAMONT****MI*QZ38606T~N3*175 MOFFAT ST                 1~N4*BROOKLYN*NY*11207~DMG*D8*19920304*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 066~MSG*RECERT MONTH=12~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*529373130~GE*1*529373130~IEA*1*529373130~