Raw X12 — CIN WY86298E

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1925*|*00501*649156931*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1925*156931*X*005010X279A1~ST*270*6931*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*WY86298E~EQ*30~DTP*291*D8*20260814~SE*13*6931~GE*1*156931~IEA*1*649156931~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1525*^*00501*542461530*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152552*542461530*X*005010X279A1~ST*271*542461530*005010X279A1~BHT*0022*11*202608131925000001*20260813*152552~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*SMITH*ISMAY****MI*WY86298E~N3*2665 DECATUR AV               23~N4*BRONX*NY*10458~DMG*D8*19530926*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260201~EB*U*IND*30**ELIGIBLE PCP~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*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*2A51F30AY23~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*542461530~GE*1*542461530~IEA*1*542461530~