Raw X12 — CIN ZE03866R

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1959*|*00501*564780388*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1959*780388*X*005010X279A1~ST*270*0388*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*ZE03866R~EQ*30~DTP*291*D8*20260813~SE*13*0388~GE*1*780388~IEA*1*564780388~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1559*^*00501*530713330*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155935*530713330*X*005010X279A1~ST*271*530713330*005010X279A1~BHT*0022*11*202608121959000001*20260812*155935~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*NELSA*A***MI*ZE03866R~N3*38       HERZL ST             H14~N4*BROOKLYN*NY*11212~DMG*D8*19430719*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=04~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*ZE03866R~LS*2120~NM1*P4*2*LOCAL 1199 SEIU HC*****PI*LOHC~N3*PO BOX 1007 TIMES SQUARE STATION~N4*NEW YORK*NY*101081007~PER*IC*PROVIDER SERVICES*TE*6464739200~LE*2120~EB*R*IND*30~REF*6P*H3359~LS*2120~NM1*P4*2*HEALTHFIRST MEDICARE PLAN*****PI*H3359~N3*HEALTHFIRST MEDICARE PLAN  PO BOX 5165~N4*NEW YORK*NY*10274~PER*IC*PROVIDER SERVICES*TE*8882601010~LE*2120~EB*R*IND*30~REF*18*9R25ET6NQ53~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*52*530713330~GE*1*530713330~IEA*1*530713330~