Raw X12 — CIN WA03064K

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2005*|*00501*565120761*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2005*120761*X*005010X279A1~ST*270*0761*005010X279A1~BHT*0022*13*202608122005000001*20260812*2005~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*202608122005000001*00000000ND~NM1*IL*1******MI*WA03064K~EQ*30~DTP*291*D8*20260813~SE*13*0761~GE*1*120761~IEA*1*565120761~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1605*^*00501*533912530*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160516*533912530*X*005010X279A1~ST*271*533912530*005010X279A1~BHT*0022*11*202608122005000001*20260812*160516~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*202608122005000001*00000000ND~NM1*IL*1*VENEZUELA*DOMINICK****MI*WA03064K~N3*505E 120TH ST                 2B~N4*NEW YORK*NY*10035~DMG*D8*19821124*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=04~LS*2120~NM1*Y2*2*VILLAGE SENIOR SERVICES CORP MAP*****PI*VM~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*R*IND*30~REF*6P*H2168~LS*2120~NM1*P4*2*VILLAGECAREMAX MEDICARE TOTAL ADVAN*****PI*H2168~N3*P O  BOX 5426~N4*HAUPPAUGE*NY*117885426~PER*IC*PROVIDER SERVICES*TE*8004696292~LE*2120~EB*R*IND*30~REF*18*2W38RK7EN42~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*43*533912530~GE*1*533912530~IEA*1*533912530~