Raw X12 — CIN RD98501M

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1921*|*00501*648912263*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1921*912263*X*005010X279A1~ST*270*2263*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*RD98501M~EQ*30~DTP*291*D8*20260814~SE*13*2263~GE*1*912263~IEA*1*648912263~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1521*^*00501*541445330*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152147*541445330*X*005010X279A1~ST*271*541445330*005010X279A1~BHT*0022*11*202608131921000001*20260813*152147~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*BANKS*JENNA****MI*RD98501M~N3*302      BAINBRIDGE STREET    6C~N4*BROOKLYN*NY*11233~DMG*D8*19430906*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20251201~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*S1~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*6P*H3330~LS*2120~NM1*P4*2*HIP MEDICARE HMO*****PI*H3330~N3*55 WATER STREET  55 WATER STREET~N4*NEW YORK CITY*NY*10041~PER*IC*PROVIDER SERVICES*TE*8004478255~LE*2120~EB*R*IND*30~REF*18*7A96F72FY57~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*45*541445330~GE*1*541445330~IEA*1*541445330~