Raw X12 — CIN RN56077D

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1921*|*00501*648908265*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1921*908265*X*005010X279A1~ST*270*8265*005010X279A1~BHT*0022*13*202608131921000001*20260813*1921~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*202608131921000001*00000000ND~NM1*IL*1******MI*RN56077D~EQ*30~DTP*291*D8*20260814~SE*13*8265~GE*1*908265~IEA*1*648908265~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1521*^*00501*541424730*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152143*541424730*X*005010X279A1~ST*271*541424730*005010X279A1~BHT*0022*11*202608131921000001*20260813*152143~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*202608131921000001*00000000ND~NM1*IL*1*ANCONA*ANGELA****MI*RN56077D~N3*1562     84 STREET~N4*BROOKLYN*NY*11228~DMG*D8*19431021*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20251101~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=11~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*18*8WG2R57WD26~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*36*541424730~GE*1*541424730~IEA*1*541424730~