Raw X12 — CIN WT61697B

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1958*|*00501*564732562*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1958*732562*X*005010X279A1~ST*270*2562*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*WT61697B~EQ*30~DTP*291*D8*20260813~SE*13*2562~GE*1*732562~IEA*1*564732562~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1558*^*00501*530533230*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155848*530533230*X*005010X279A1~ST*271*530533230*005010X279A1~BHT*0022*11*202608121958000001*20260812*155848~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*LAWRENCE*ELIESE*R***MI*WT61697B~N3*470 BEACH 67TH ST~N4*ARVERNE*NY*11692~DMG*D8*19600714*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260401~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 589~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*R*IND*30~REF*6P*H5549~LS*2120~NM1*P4*2*VNS CHOICE MEDICARE*****PI*H5549~N3*1250 BROADWAY  3RD FLOOR~N4*NEW YORK*NY*10001~PER*IC*PROVIDER SERVICES*TE*8665976674~LE*2120~EB*R*IND*30~REF*18*8XG9HP1WR37~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*44*530533230~GE*1*530533230~IEA*1*530533230~