Raw X12 — CIN SC49831J

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1925*|*00501*649108461*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1925*108461*X*005010X279A1~ST*270*8461*005010X279A1~BHT*0022*13*202608131925000001*20260813*1925~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*202608131925000001*00000000ND~NM1*IL*1******MI*SC49831J~EQ*30~DTP*291*D8*20260814~SE*13*8461~GE*1*108461~IEA*1*649108461~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1525*^*00501*542259430*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152504*542259430*X*005010X279A1~ST*271*542259430*005010X279A1~BHT*0022*11*202608131925000001*20260813*152504~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*202608131925000001*00000000ND~NM1*IL*1*SOUFFRANT*PIERRE****MI*SC49831J~N3*1 LONG BEACH ROAD~N4*ISLAND PARK*NY*11203~DMG*D8*19471111*M~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20251201~EB*U*IND*30**ELIGIBLE PCP~MSG*N6~MSG*CNTY CD=66 588~LS*2120~NM1*Y2*2*VNS CHOICE PARTIAL LTC*****PI*VC~N3*220 E 42ND ST FL 6~N4*NEW YORK*NY*100175831~PER*IC*PROVIDER SERVICES*TE*8667830222~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*1*IND*88~EB*R*IND*30~REF*18*3CT0TD8XY22~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*34*542259430~GE*1*542259430~IEA*1*542259430~