Raw X12 — CIN UP33518U

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2001*|*00501*564885491*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2001*885491*X*005010X279A1~ST*270*5491*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*UP33518U~EQ*30~DTP*291*D8*20260813~SE*13*5491~GE*1*885491~IEA*1*564885491~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1601*^*00501*533042430*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160121*533042430*X*005010X279A1~ST*271*533042430*005010X279A1~BHT*0022*11*202608122001000001*20260812*160121~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*PEREZ*ANA****MI*UP33518U~N3*3115     SEDGWICK AVENUE      3D~N4*BRONX*NY*10463~DMG*D8*19380927*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260301~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~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*6P*H0423~LS*2120~NM1*P4*2*METROPLUS HEALTH PLAN, INC.*****PI*H0423~N3*160 WATER STREET~N4*NEW YORK*NY*10038~PER*IC*PROVIDER SERVICES*TE*8669860356~LE*2120~EB*R*IND*30~REF*18*7MA6UX0KJ75~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*533042430~GE*1*533042430~IEA*1*533042430~