Raw X12 — CIN VK02030N

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2001*|*00501*564892503*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2001*892503*X*005010X279A1~ST*270*2503*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*VK02030N~EQ*30~DTP*291*D8*20260813~SE*13*2503~GE*1*892503~IEA*1*564892503~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1601*^*00501*533068030*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160128*533068030*X*005010X279A1~ST*271*533068030*005010X279A1~BHT*0022*11*202608122001000001*20260812*160128~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*CHRISTINE****MI*VK02030N~N3*303      E 158TH ST           3G~N4*BRONX*NY*10451~DMG*D8*19751002*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260801~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*CNTY CD=66 038~MSG*RECERT MONTH=12~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*533068030~GE*1*533068030~IEA*1*533068030~