Raw X12 — CIN ZQ72214S

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2001*|*00501*564871095*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2001*871095*X*005010X279A1~ST*270*1095*005010X279A1~BHT*0022*13*202608122001000001*20260812*2001~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*202608122001000001*00000000ND~NM1*IL*1******MI*ZQ72214S~EQ*30~DTP*291*D8*20260813~SE*13*1095~GE*1*871095~IEA*1*564871095~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1601*^*00501*532884230*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160106*532884230*X*005010X279A1~ST*271*532884230*005010X279A1~BHT*0022*11*202608122001000001*20260812*160106~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*202608122001000001*00000000ND~NM1*IL*1*PARKER*JANIE*L***MI*ZQ72214S~N3*525      FOUNTAIN AVENUE      5A~N4*BROOKLYN*NY*11208~DMG*D8*19520806*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=09~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*6P*H3387~LS*2120~NM1*P4*2*UNITEDHEALTHCARE DUAL COMPLETE*****PI*H3387~N3*P O BOX 917~N4*NEW YORK*NY*10269~PER*IC*PROVIDER SERVICES*TE*8005144912~LE*2120~EB*R*IND*30~REF*18*7A27QC1QF35~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*44*532884230~GE*1*532884230~IEA*1*532884230~