Raw X12 — CIN US68665V

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1957*|*00501*564660253*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1957*660253*X*005010X279A1~ST*270*0253*005010X279A1~BHT*0022*13*202608121957000001*20260812*1957~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*202608121957000001*00000000ND~NM1*IL*1******MI*US68665V~EQ*30~DTP*291*D8*20260813~SE*13*0253~GE*1*660253~IEA*1*564660253~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1557*^*00501*530262030*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155735*530262030*X*005010X279A1~ST*271*530262030*005010X279A1~BHT*0022*11*202608121957000001*20260812*155735~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*202608121957000001*00000000ND~NM1*IL*1*HECKSTALL*MOSES*E***MI*US68665V~N3*291 WYONA ST                  2~N4*BROOKLYN*NY*11207~DMG*D8*19961221*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20251101~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*PD~MSG*CNTY CD=66 5A6~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*DIRECT CARE MANAGEMENT LLC*****XX*1427718972~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*NORTH SHORE UNIVERSITY HOSPITAL*****XX*1932472107~LE*2120~SE*40*530262030~GE*1*530262030~IEA*1*530262030~