Raw X12 — CIN YS55608V

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1959*|*00501*564774383*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1959*774383*X*005010X279A1~ST*270*4383*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*YS55608V~EQ*30~DTP*291*D8*20260813~SE*13*4383~GE*1*774383~IEA*1*564774383~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1559*^*00501*530690030*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155930*530690030*X*005010X279A1~ST*271*530690030*005010X279A1~BHT*0022*11*202608121959000001*20260812*155930~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*MARTINEZ*MELANIA****MI*YS55608V~N3*767 BLAKE AVE                 2A~N4*BROOKLYN*NY*11207~DMG*D8*19620312*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260401~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*PD~MSG*CNTY CD=66 500~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*METRO CARE MANAGEMENT LLC*****XX*1922565118~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*COORDINATED BEHAVIORAL CARE INC*****XX*1730451071~LE*2120~SE*40*530690030~GE*1*530690030~IEA*1*530690030~