Raw X12 — CIN WY20651R

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1922*|*00501*648975326*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1922*975326*X*005010X279A1~ST*270*5326*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*WY20651R~EQ*30~DTP*291*D8*20260814~SE*13*5326~GE*1*975326~IEA*1*648975326~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1522*^*00501*541700430*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152250*541700430*X*005010X279A1~ST*271*541700430*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*PELLOTREYES*ENRIQUE****MI*WY20651R~N3*738 ALBANY AVE                5A~N4*BROOKLYN*NY*11203~DMG*D8*19531201*M~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~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*H5549~LS*2120~NM1*P4*2*VNS CHOICE MEDICARE*****PI*H5549~N3*1250 BROADWAY  3RD FLOOR~N4*NEW YORK*NY*10001~PER*IC*PROVIDER SERVICES*TE*8665976674~LE*2120~EB*R*IND*30~REF*18*V70112885~REF*6P*1731320~LS*2120~NM1*P4*2*UNITED HEALTH CARE (DENTAL)*****PI*F7D~N3*PO BOX 30560~N4*BETHESDA*MD*208240560~PER*IC*PROVIDER SERVICES*TE*8668776187~LE*2120~EB*R*IND*30~REF*18*4PM2VW4HX26~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*52*541700430~GE*1*541700430~IEA*1*541700430~