Raw X12 — CIN WU54916A

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1956*|*00501*564609204*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1956*609204*X*005010X279A1~ST*270*9204*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*WU54916A~EQ*30~DTP*291*D8*20260813~SE*13*9204~GE*1*609204~IEA*1*564609204~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1556*^*00501*530070530*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155644*530070530*X*005010X279A1~ST*271*530070530*005010X279A1~BHT*0022*11*202608121956000001*20260812*155644~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*GOLD*MYRON****MI*WU54916A~N3*215      W W 83RD ST STREET   12F~N4*NEW YORK*NY*10024~DMG*D8*19401202*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~MSG*RECERT MONTH=05~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*18*6A31QP2CD14~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*36*530070530~GE*1*530070530~IEA*1*530070530~