Raw X12 — CIN ZD93721J

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2002*|*00501*564969593*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2002*969593*X*005010X279A1~ST*270*9593*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*ZD93721J~EQ*30~DTP*291*D8*20260813~SE*13*9593~GE*1*969593~IEA*1*564969593~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1602*^*00501*533372130*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160245*533372130*X*005010X279A1~ST*271*533372130*005010X279A1~BHT*0022*11*202608122002000001*20260812*160245~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*RODRIGUEZ*MARIA****MI*ZD93721J~N3*542 WEST 159TH ST             2A~N4*NEW YORK*NY*10032~DMG*D8*19471220*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*CNTY CD=66 5H9~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*H5549~LS*2120~NM1*P4*2*VNS CHOICE MEDICARE*****PI*H5549~N3*1250 BROADWAY  3RD FLOOR~N4*NEW YORK*NY*10001~PER*IC*PROVIDER SERVICES*TE*8665976674~LE*2120~EB*R*IND*30~REF*18*5UA2VH8KG04~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*533372130~GE*1*533372130~IEA*1*533372130~