Raw X12 — CIN YF14575G

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2003*|*00501*564984616*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2003*984616*X*005010X279A1~ST*270*4616*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*YF14575G~EQ*30~DTP*291*D8*20260813~SE*13*4616~GE*1*984616~IEA*1*564984616~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1603*^*00501*533428130*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160300*533428130*X*005010X279A1~ST*271*533428130*005010X279A1~BHT*0022*11*202608122003000001*20260812*160300~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*RAFAEL****MI*YF14575G~N3*430      DUMONT AVE           11G~N4*BROOKLYN*NY*11212~DMG*D8*19361024*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260401~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*H9~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=02~LS*2120~NM1*Y2*2*VNS CHOICE PLUS M/M MAP*****PI*YN~N3*220 E 42ND ST FL 6~N4*NEW YORK*NY*100175831~PER*IC*PROVIDER SERVICES*TE*8669867691~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~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*6WM4K95EF01~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*44*533428130~GE*1*533428130~IEA*1*533428130~