Raw X12 — CIN UU75520K

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1958*|*00501*564725327*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1958*725327*X*005010X279A1~ST*270*5327*005010X279A1~BHT*0022*13*202608121958000001*20260812*1958~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*202608121958000001*00000000ND~NM1*IL*1******MI*UU75520K~EQ*30~DTP*291*D8*20260813~SE*13*5327~GE*1*725327~IEA*1*564725327~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1558*^*00501*530507030*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155841*530507030*X*005010X279A1~ST*271*530507030*005010X279A1~BHT*0022*11*202608121958000001*20260812*155841~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*202608121958000001*00000000ND~NM1*IL*1*LAMAR*AUDREY*V***MI*UU75520K~N3*113      W 144TH ST APT 1A~N4*NEW YORK*NY*10030~DMG*D8*19650621*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260501~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=03~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*6P*H5991~LS*2120~NM1*P4*2*EMBLEMHEALTH MEDICARE HMO*****PI*H5991~N3*55 WATER ST~N4*NEW YORK*NY*100418190~PER*IC*PROVIDER SERVICES*TE*8772344499~LE*2120~EB*R*IND*30~REF*18*9DW0H95YM05~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*44*530507030~GE*1*530507030~IEA*1*530507030~