Raw X12 — CIN UP54749Z

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1923*|*00501*648981856*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1923*981856*X*005010X279A1~ST*270*1856*005010X279A1~BHT*0022*13*202608131923000001*20260813*1923~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*202608131923000001*00000000ND~NM1*IL*1******MI*UP54749Z~EQ*30~DTP*291*D8*20260814~SE*13*1856~GE*1*981856~IEA*1*648981856~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1522*^*00501*541722730*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152257*541722730*X*005010X279A1~ST*271*541722730*005010X279A1~BHT*0022*11*202608131923000001*20260813*152257~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*202608131923000001*00000000ND~NM1*IL*1*RAFAELOV*MAYA****MI*UP54749Z~N3*155      BEACH 19TH ST        15A~N4*FAR ROCKAWAY*NY*11691~DMG*D8*19500701*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=10~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*6TV2TK5EE28~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*36*541722730~GE*1*541722730~IEA*1*541722730~