Raw X12 — CIN YY93972E

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1954*|*00501*564482307*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1954*482307*X*005010X279A1~ST*270*2307*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*YY93972E~EQ*30~DTP*291*D8*20260813~SE*13*2307~GE*1*482307~IEA*1*564482307~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1554*^*00501*529592930*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155437*529592930*X*005010X279A1~ST*271*529592930*005010X279A1~BHT*0022*11*202608121954000001*20260812*155437~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*DAMES*MICHAEL*E***MI*YY93972E~N3*2328 NEWKIRK AVE              1C~N4*BROOKLYN*NY*11226~DMG*D8*19540806*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20251201~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~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*063483084~REF*6P*PCA001~LS*2120~NM1*P4*2*DAVIS VISION*****PI*90~N3*PO BOX 1501~N4*LATHAM*NY*121108001~PER*IC*PROVIDER SERVICES*TE*8009995431~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*6CE2XX0QG27~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*51*529592930~GE*1*529592930~IEA*1*529592930~