Raw X12 — CIN YR46988W

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1922*|*00501*648973320*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1922*973320*X*005010X279A1~ST*270*3320*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*YR46988W~EQ*30~DTP*291*D8*20260814~SE*13*3320~GE*1*973320~IEA*1*648973320~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1522*^*00501*541695230*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152250*541695230*X*005010X279A1~ST*271*541695230*005010X279A1~BHT*0022*11*202608131922000001*20260813*152250~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*PEDROZA*MARIA****MI*YR46988W~N3*1349 1349 GATES AVE~N4*BROOKLYN*NY*11221~DMG*D8*19411005*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260301~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=08~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*W*IND*CQ~LS*2120~NM1*Y2*2*NORTH SHORE UNIVERSITY HOSPITAL*****XX*1932472107~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*NORTH SHORE UNIVERSITY HOSPITAL*****XX*1932472107~LE*2120~EB*R*IND*30~REF*6P*H3387~LS*2120~NM1*P4*2*UNITEDHEALTHCARE DUAL COMPLETE*****PI*H3387~N3*P O BOX 917~N4*NEW YORK*NY*10269~PER*IC*PROVIDER SERVICES*TE*8005144912~LE*2120~EB*R*IND*30~REF*18*3MQ8U53PW28~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*54*541695230~GE*1*541695230~IEA*1*541695230~