Raw X12 — CIN YZ23440Q

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2003*|*00501*564996629*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2003*996629*X*005010X279A1~ST*270*6629*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*YZ23440Q~EQ*30~DTP*291*D8*20260813~SE*13*6629~GE*1*996629~IEA*1*564996629~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1603*^*00501*533478830*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160312*533478830*X*005010X279A1~ST*271*533478830*005010X279A1~BHT*0022*11*202608122003000001*20260812*160312~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*ROMAN*MARIA****MI*YZ23440Q~N3*408 WOODBINE STREET           1~N4*BROOKLYN*NY*11237~DMG*D8*19530620*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=12~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*1YR6CN1FU76~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*533478830~GE*1*533478830~IEA*1*533478830~