Raw X12 — CIN NV91630N

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1956*|*00501*564598399*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1956*598399*X*005010X279A1~ST*270*8399*005010X279A1~BHT*0022*13*202608121956000001*20260812*1956~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*202608121956000001*00000000ND~NM1*IL*1******MI*NV91630N~EQ*30~DTP*291*D8*20260813~SE*13*8399~GE*1*598399~IEA*1*564598399~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1556*^*00501*530033530*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155633*530033530*X*005010X279A1~ST*271*530033530*005010X279A1~BHT*0022*11*202608121956000001*20260812*155633~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*202608121956000001*00000000ND~NM1*IL*1*GARCIA*JUSTIN*D***MI*NV91630N~N3*1726 DAVIDSON AVE             6E~N4*BRONX*NY*10453~DMG*D8*20020304*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260301~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*CNTY CD=66 038~MSG*RECERT MONTH=12~LS*2120~NM1*Y2*2*VNS CHOICE PARTIAL LTC*****PI*VC~N3*220 E 42ND ST FL 6~N4*NEW YORK*NY*100175831~PER*IC*PROVIDER SERVICES*TE*8667830222~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*1*IND*88~SE*30*530033530~GE*1*530033530~IEA*1*530033530~