Raw X12 — CIN YD62051T

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2005*|*00501*565152794*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2005*152794*X*005010X279A1~ST*270*2794*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*YD62051T~EQ*30~DTP*291*D8*20260813~SE*13*2794~GE*1*152794~IEA*1*565152794~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1605*^*00501*534030030*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160548*534030030*X*005010X279A1~ST*271*534030030*005010X279A1~BHT*0022*11*202608122005000001*20260812*160548~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*WILLIAMS*TANGERINEA****MI*YD62051T~N3*110 BARUCH DR                 9D~N4*NEW YORK*NY*10002~DMG*D8*19630429*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~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~EB*W*IND*CQ~LS*2120~NM1*Y2*2*ESSEN MEDICAL ASSOCIATES PC*****XX*1366418709~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*MONTEFIORE MEDICAL CENTER*****XX*1831461847~LE*2120~SE*40*534030030~GE*1*534030030~IEA*1*534030030~