Raw X12 — CIN VD43099C

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2003*|*00501*564982902*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2003*982902*X*005010X279A1~ST*270*2902*005010X279A1~BHT*0022*13*202608122003000001*20260812*2003~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*202608122003000001*00000000ND~NM1*IL*1******MI*VD43099C~EQ*30~DTP*291*D8*20260813~SE*13*2902~GE*1*982902~IEA*1*564982902~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1602*^*00501*533422430*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160258*533422430*X*005010X279A1~ST*271*533422430*005010X279A1~BHT*0022*11*202608122003000001*20260812*160258~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*202608122003000001*00000000ND~NM1*IL*1*RODRIGUEZ*MARIA*M***MI*VD43099C~N3*3021 AVENUE W                 5F~N4*BROOKLYN*NY*11229~DMG*D8*19640723*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260501~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~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~SE*30*533422430~GE*1*533422430~IEA*1*533422430~