Raw X12 — CIN PK11148Z

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2001*|*00501*564876482*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2001*876482*X*005010X279A1~ST*270*6482*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*PK11148Z~EQ*30~DTP*291*D8*20260813~SE*13*6482~GE*1*876482~IEA*1*564876482~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1601*^*00501*533009430*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160112*533009430*X*005010X279A1~ST*271*533009430*005010X279A1~BHT*0022*11*202608122001000001*20260812*160112~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*PENA*MARIA*A***MI*PK11148Z~N3*193 ALBANY AVE~N4*BROOKLYN*NY*11213~DMG*D8*19650402*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260201~EB*U*IND*30**ELIGIBLE PCP~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~SE*30*533009430~GE*1*533009430~IEA*1*533009430~