Raw X12 — CIN KP05085W

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1959*|*00501*564765372*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1959*765372*X*005010X279A1~ST*270*5372*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*KP05085W~EQ*30~DTP*291*D8*20260813~SE*13*5372~GE*1*765372~IEA*1*564765372~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1559*^*00501*530657830*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155920*530657830*X*005010X279A1~ST*271*530657830*005010X279A1~BHT*0022*11*202608121959000001*20260812*155920~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*MANISCALCO*LILLIAN****MI*KP05085W~N3*439 GUY LOMBARDO AVE~N4*FREEPORT*NY*11520~DMG*D8*19410101*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20250901~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*NYCK90322150~REF*6P*157158002R~LS*2120~NM1*P4*2*GROUP HEALTH INC.*****PI*06~N3*2 WALL ST~N4*ALBANY*NY*122053828~PER*IC*PROVIDER SERVICES*TE*8006242414~LE*2120~EB*R*IND*30~REF*18*6UG7E87MC45~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*45*530657830~GE*1*530657830~IEA*1*530657830~