Raw X12 — CIN ZW57867B

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1954*|*00501*564490455*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1954*490455*X*005010X279A1~ST*270*0455*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*ZW57867B~EQ*30~DTP*291*D8*20260813~SE*13*0455~GE*1*490455~IEA*1*564490455~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1554*^*00501*529623730*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155446*529623730*X*005010X279A1~ST*271*529623730*005010X279A1~BHT*0022*11*202608121954000001*20260812*155446~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*DAVIS*JUDY****MI*ZW57867B~N3*1141     FDR DR               10A~N4*NEW YORK*NY*10009~DMG*D8*19590926*F~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=66 013~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*529623730~GE*1*529623730~IEA*1*529623730~