Raw X12 — CIN YU21293M

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1922*|*00501*648924268*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1922*924268*X*005010X279A1~ST*270*4268*005010X279A1~BHT*0022*13*202608131922000001*20260813*1922~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*202608131922000001*00000000ND~NM1*IL*1******MI*YU21293M~EQ*30~DTP*291*D8*20260814~SE*13*4268~GE*1*924268~IEA*1*648924268~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1521*^*00501*541492930*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152159*541492930*X*005010X279A1~ST*271*541492930*005010X279A1~BHT*0022*11*202608131922000001*20260813*152159~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*202608131922000001*00000000ND~NM1*IL*1*DELMONTE*CHARLES****MI*YU21293M~N3*P O BOX 808~N4*NEW YORK*NY*10276~DMG*D8*19391220*M~DTP*472*D8*20260813~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 SERVICES CORP MAP*****PI*VM~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*W*IND*CQ~LS*2120~NM1*Y2*2*METRO CARE MANAGEMENT LLC*****XX*1922565118~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*COORDINATED BEHAVIORAL CARE INC*****XX*1730451071~LE*2120~EB*R*IND*30~REF*6P*H2168~LS*2120~NM1*P4*2*VILLAGECAREMAX MEDICARE TOTAL ADVAN*****PI*H2168~N3*P O  BOX 5426~N4*HAUPPAUGE*NY*117885426~PER*IC*PROVIDER SERVICES*TE*8004696292~LE*2120~EB*R*IND*30~REF*18*2W03JR4WV95~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*52*541492930~GE*1*541492930~IEA*1*541492930~