Raw X12 — CIN WU02688A

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1919*|*00501*648759087*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1919*759087*X*005010X279A1~ST*270*9087*005010X279A1~BHT*0022*13*202608131919000001*20260813*1919~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*202608131919000001*00000000ND~NM1*IL*1******MI*WU02688A~EQ*30~DTP*291*D8*20260814~SE*13*9087~GE*1*759087~IEA*1*648759087~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1519*^*00501*538161630*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151914*538161630*X*005010X279A1~ST*271*538161630*005010X279A1~BHT*0022*11*202608131919000001*20260813*151914~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*202608131919000001*00000000ND~NM1*IL*1*AQUINO*VENERANDA****MI*WU02688A~N3*521      TIMPSON PL~N4*BRONX*NY*10455~DMG*D8*19551114*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260501~EB*1*IND*30**Community Coverage w/CBLTC~MSG*PD~MSG*60~MSG*CNTY CD=66 523~MSG*RECERT MONTH=12~EB*B*IND*30***29*0~EB*1*IND*1~EB*1*IND*4~EB*1*IND*5~EB*1*IND*33~EB*1*IND*35~EB*1*IND*47~EB*1*IND*48~EB*1*IND*50~EB*1*IND*86~EB*1*IND*88~EB*1*IND*98~EB*1*IND*AG~EB*1*IND*AL~EB*1*IND*MH~EB*1*IND*UC~EB*R*IND*30~REF*18*8RX8MP7XT31~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*538161630~GE*1*538161630~IEA*1*538161630~