Raw X12 — CIN ZW93367A

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2002*|*00501*564953377*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2002*953377*X*005010X279A1~ST*270*3377*005010X279A1~BHT*0022*13*202608122002000001*20260812*2002~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*202608122002000001*00000000ND~NM1*IL*1******MI*ZW93367A~EQ*30~DTP*291*D8*20260813~SE*13*3377~GE*1*953377~IEA*1*564953377~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1602*^*00501*533303930*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160229*533303930*X*005010X279A1~ST*271*533303930*005010X279A1~BHT*0022*11*202608122002000001*20260812*160229~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*202608122002000001*00000000ND~NM1*IL*1*RIVERA*LEOPOLDO****MI*ZW93367A~N3*22       MOFFAT ST            4I~N4*BROOKLYN*NY*11207~DMG*D8*19450714*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260201~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=01~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*W*IND*CQ~LS*2120~NM1*Y2*2*NORTH SHORE UNIVERSITY HOSPITAL*****XX*1932472107~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*NORTH SHORE UNIVERSITY HOSPITAL*****XX*1932472107~LE*2120~EB*R*IND*30~REF*6P*H3359~LS*2120~NM1*P4*2*HEALTHFIRST MEDICARE PLAN*****PI*H3359~N3*HEALTHFIRST MEDICARE PLAN  PO BOX 5165~N4*NEW YORK*NY*10274~PER*IC*PROVIDER SERVICES*TE*8882601010~LE*2120~EB*R*IND*30~REF*18*7MU2TR3VY02~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*54*533303930~GE*1*533303930~IEA*1*533303930~