Raw X12 — CIN ZT89297K

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1959*|*00501*564762602*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1959*762602*X*005010X279A1~ST*270*2602*005010X279A1~BHT*0022*13*202608121959000001*20260812*1959~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*202608121959000001*00000000ND~NM1*IL*1******MI*ZT89297K~EQ*30~DTP*291*D8*20260813~SE*13*2602~GE*1*762602~IEA*1*564762602~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1559*^*00501*530645430*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155918*530645430*X*005010X279A1~ST*271*530645430*005010X279A1~BHT*0022*11*202608121959000001*20260812*155918~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*202608121959000001*00000000ND~NM1*IL*1*MANCINEZ*ZORAIDA****MI*ZT89297K~N3*160 SCHROEDERS AVENUE         7C~N4*BROOKLYN*NY*11239~DMG*D8*19540625*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260301~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*PD~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=02~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*NORTH SHORE UNIVERSITY HOSPITAL*****XX*1932472107~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*NORTH SHORE UNIVERSITY HOSPITAL*****XX*1932472107~LE*2120~EB*R*IND*30~REF*6P*H3312~LS*2120~NM1*P4*2*AETNA MEDICARE*****PI*H3312~N3*151 FARMINGTON AVENUE~N4*HARTFORD*CT*06156~PER*IC*PROVIDER SERVICES*TE*8002825366~LE*2120~EB*R*IND*30~REF*18*7TT7FK4KG50~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*55*530645430~GE*1*530645430~IEA*1*530645430~