Raw X12 — CIN ZX08244F

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1953*|*00501*564424362*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1953*424362*X*005010X279A1~ST*270*4362*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*ZX08244F~EQ*30~DTP*291*D8*20260813~SE*13*4362~GE*1*424362~IEA*1*564424362~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1553*^*00501*529381530*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155340*529381530*X*005010X279A1~ST*271*529381530*005010X279A1~BHT*0022*11*202608121953000001*20260812*155340~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*CLARK*CHANIZE****MI*ZX08244F~N3*1128 FINDLAY AVENUE           1A~N4*BRONX*NY*10456~DMG*D8*19550215*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=09~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*18195672~REF*6P*00000D069250~LS*2120~NM1*P4*2*GROUP HEALTH INC.*****PI*06~N3*2 WALL ST~N4*ALBANY*NY*122053828~PER*IC*PROVIDER SERVICES*TE*8006242414~LE*2120~EB*R*IND*30~REF*6P*H3387~LS*2120~NM1*P4*2*UNITEDHEALTHCARE DUAL COMPLETE*****PI*H3387~N3*P O BOX 917~N4*NEW YORK*NY*10269~PER*IC*PROVIDER SERVICES*TE*8005144912~LE*2120~EB*R*IND*30~REF*18*4P16E10WW66~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*53*529381530~GE*1*529381530~IEA*1*529381530~