Raw X12 — CIN NU56174B

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1955*|*00501*564517083*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1955*517083*X*005010X279A1~ST*270*7083*005010X279A1~BHT*0022*13*202608121955000001*20260812*1955~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*202608121955000001*00000000ND~NM1*IL*1******MI*NU56174B~EQ*30~DTP*291*D8*20260813~SE*13*7083~GE*1*517083~IEA*1*564517083~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1555*^*00501*529728130*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155512*529728130*X*005010X279A1~ST*271*529728130*005010X279A1~BHT*0022*11*202608121955000001*20260812*155512~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*202608121955000001*00000000ND~NM1*IL*1*DONALDSON*RALPH****MI*NU56174B~N3*36       WEST GUNHILL ROAD    4C~N4*BRONX*NY*10467~DMG*D8*19641206*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260801~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~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*W*IND*CQ~LS*2120~NM1*Y2*2*JEMCARE LLC*****XX*1265926216~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*COMMUNITY CARE MANAGEMENT PARTNERS*****XX*1366780850~LE*2120~SE*40*529728130~GE*1*529728130~IEA*1*529728130~