Raw X12 — CIN RM73355T

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2000*|*00501*564816425*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2000*816425*X*005010X279A1~ST*270*6425*005010X279A1~BHT*0022*13*202608122000000001*20260812*2000~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*202608122000000001*00000000ND~NM1*IL*1******MI*RM73355T~EQ*30~DTP*291*D8*20260813~SE*13*6425~GE*1*816425~IEA*1*564816425~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1600*^*00501*530951230*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160012*530951230*X*005010X279A1~ST*271*530951230*005010X279A1~BHT*0022*11*202608122000000001*20260812*160012~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*202608122000000001*00000000ND~NM1*IL*1*MINAYA*RAMON****MI*RM73355T~N3*601      PARK AVE             1A~N4*BROOKLYN*NY*11206~DMG*D8*19660203*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260501~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*CNTY CD=66 5H9~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~SE*29*530951230~GE*1*530951230~IEA*1*530951230~