Raw X12 — CIN TX70124D

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2005*|*00501*565144785*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2005*144785*X*005010X279A1~ST*270*4785*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*TX70124D~EQ*30~DTP*291*D8*20260813~SE*13*4785~GE*1*144785~IEA*1*565144785~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1605*^*00501*534003430*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160540*534003430*X*005010X279A1~ST*271*534003430*005010X279A1~BHT*0022*11*202608122005000001*20260812*160540~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*WILKINS*BARBARA*A***MI*TX70124D~N3*1309     PUTNAM AVE           1A~N4*BROOKLYN*NY*11221~DMG*D8*19391227*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260301~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=02~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*18*31006912711~REF*6P*0~LS*2120~NM1*P4*2*AARP*****PI*AP~N3*P O  BOX 13999~N4*PHILADELPHIA*PA*191870216~PER*IC*PROVIDER SERVICES*TE*8005235880~LE*2120~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*4KX7WP7QN66~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*53*534003430~GE*1*534003430~IEA*1*534003430~