Raw X12 — CIN DP42054J

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2001*|*00501*564909521*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2001*909521*X*005010X279A1~ST*270*9521*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*DP42054J~EQ*30~DTP*291*D8*20260813~SE*13*9521~GE*1*909521~IEA*1*564909521~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1601*^*00501*533128530*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160145*533128530*X*005010X279A1~ST*271*533128530*005010X279A1~BHT*0022*11*202608122001000001*20260812*160145~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*POOLE*JAMES****MI*DP42054J~N3*546 S 99 AVENUE FLOOR 2 BACK ROOM~N4*MOUNT VERNON*NY*10550~DMG*D8*19390828*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20251101~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*CNTY CD=55~MSG*RECERT MONTH=07~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*18*966294305~REF*6P*66071~LS*2120~NM1*P4*2*OPTUM RX*****PI*ORX~N3*PO BOX 8082~N4*WAUSAU*WI*544028082~PER*IC*PROVIDER SERVICES*TE*8002071561~LE*2120~EB*R*IND*30~REF*6P*H3312~LS*2120~NM1*P4*2*AETNA MEDICARE*****PI*H3312~N3*151 FARMINGTON AVENUE~N4*HARTFORD*CT*06156~PER*IC*PROVIDER SERVICES*TE*8002825366~LE*2120~EB*R*IND*30~REF*18*3H10G83UX18~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*52*533128530~GE*1*533128530~IEA*1*533128530~