Raw X12 — CIN YY88248P

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1954*|*00501*564459027*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1954*459027*X*005010X279A1~ST*270*9027*005010X279A1~BHT*0022*13*202608121954000001*20260812*1954~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*202608121954000001*00000000ND~NM1*IL*1******MI*YY88248P~EQ*30~DTP*291*D8*20260813~SE*13*9027~GE*1*459027~IEA*1*564459027~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1554*^*00501*529509430*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155414*529509430*X*005010X279A1~ST*271*529509430*005010X279A1~BHT*0022*11*202608121954000001*20260812*155414~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*202608121954000001*00000000ND~NM1*IL*1*CRICHLOW*ESTELVINA****MI*YY88248P~N3*304 ST JOHNS PLACE            1K~N4*BROOKLYN*NY*11238~DMG*D8*19541129*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260201~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=07~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*H3359~LS*2120~NM1*P4*2*HEALTHFIRST MEDICARE PLAN*****PI*H3359~N3*HEALTHFIRST MEDICARE PLAN  PO BOX 5165~N4*NEW YORK*NY*10274~PER*IC*PROVIDER SERVICES*TE*8882601010~LE*2120~EB*R*IND*30~REF*18*1CR0FV4DU17~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*44*529509430~GE*1*529509430~IEA*1*529509430~