Raw X12 — CIN ZC07500A

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1959*|*00501*564786414*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1959*786414*X*005010X279A1~ST*270*6414*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*ZC07500A~EQ*30~DTP*291*D8*20260813~SE*13*6414~GE*1*786414~IEA*1*564786414~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1559*^*00501*530735330*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155942*530735330*X*005010X279A1~ST*271*530735330*005010X279A1~BHT*0022*11*202608121959000001*20260812*155942~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*MATOS*NANCY****MI*ZC07500A~N3*2406     FREDRICK DOUGLAS BOU 3D~N4*NEW YORK*NY*10027~DMG*D8*19570302*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=01~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*115506408~REF*6P*SOL072~LS*2120~NM1*P4*2*DAVIS VISION*****PI*90~N3*PO BOX 1501~N4*LATHAM*NY*121108001~PER*IC*PROVIDER SERVICES*TE*8009995431~LE*2120~EB*R*IND*30~REF*6P*H8432~LS*2120~NM1*P4*2*EMPIRE MEDIBLUE CORE*****PI*H8432~N3*EMPIRE MEDIBLUE*PO BOX 1407 CHURCH STREET STATION~N4*NEW YORK*NY*100081407~PER*IC*PROVIDER SERVICES*TE*8557311090~LE*2120~EB*R*IND*30~REF*18*7Y37WE1NH30~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*53*530735330~GE*1*530735330~IEA*1*530735330~