Raw X12 — CIN VX24030T

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2007*|*00501*565270922*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2007*270922*X*005010X279A1~ST*270*0922*005010X279A1~BHT*0022*13*202608122007000001*20260812*2007~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*202608122007000001*00000000ND~NM1*IL*1******MI*VX24030T~EQ*30~DTP*291*D8*20260813~SE*13*0922~GE*1*270922~IEA*1*565270922~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1607*^*00501*534450930*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160746*534450930*X*005010X279A1~ST*271*534450930*005010X279A1~BHT*0022*11*202608122007000001*20260812*160746~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*202608122007000001*00000000ND~NM1*IL*1*THOMPSON*DERECK*F***MI*VX24030T~N3*953 DEKALB AVE                2D~N4*BROOKLYN*NY*11221~DMG*D8*19580118*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~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*R*IND*30~REF*6P*H3359~LS*2120~NM1*P4*2*HEALTHFIRST MEDICARE PLAN*****PI*H3359~N3*HEALTHFIRST MEDICARE PLAN  PO BOX 5165~N4*NEW YORK*NY*10274~PER*IC*PROVIDER SERVICES*TE*8882601010~LE*2120~EB*R*IND*30~REF*18*8NG0PE5EK42~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*534450930~GE*1*534450930~IEA*1*534450930~