Raw X12 — CIN RT99930U

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1926*|*00501*649179955*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1926*179955*X*005010X279A1~ST*270*9955*005010X279A1~BHT*0022*13*202608131926000001*20260813*1926~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*202608131926000001*00000000ND~NM1*IL*1******MI*RT99930U~EQ*30~DTP*291*D8*20260814~SE*13*9955~GE*1*179955~IEA*1*649179955~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1526*^*00501*542558030*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152615*542558030*X*005010X279A1~ST*271*542558030*005010X279A1~BHT*0022*11*202608131926000001*20260813*152615~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*202608131926000001*00000000ND~NM1*IL*1*DESIMONE*ANIELLO****MI*RT99930U~N3*109 MONRONE AVE               2FL~N4*STATEN ISLAND*NY*10301~DMG*D8*19451013*M~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20251001~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=03~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*H8432~LS*2120~NM1*P4*2*EMPIRE MEDIBLUE CORE*****PI*H8432~N3*EMPIRE MEDIBLUE*PO BOX 1407 CHURCH STREET STATION~N4*NEW YORK*NY*100081407~PER*IC*PROVIDER SERVICES*TE*8557311090~LE*2120~EB*R*IND*30~REF*18*7J12WE0JQ01~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*44*542558030~GE*1*542558030~IEA*1*542558030~