Raw X12 — CIN TV86365S

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1926*|*00501*649181957*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1926*181957*X*005010X279A1~ST*270*1957*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*TV86365S~EQ*30~DTP*291*D8*20260814~SE*13*1957~GE*1*181957~IEA*1*649181957~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1526*^*00501*542566130*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152617*542566130*X*005010X279A1~ST*271*542566130*005010X279A1~BHT*0022*11*202608131926000001*20260813*152617~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*PICKENS*ALRISSA*D***MI*TV86365S~N3*2240 EAST TREMONT AVE         TB~N4*BRONX*NY*10462~DMG*D8*19520925*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=05~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*H2001~LS*2120~NM1*P4*2*UNITEDHEALTHCARE*****PI*H2001~N3*PO BOX 29675~N4*HOT SPRINGS*AR*71903~PER*IC*PROVIDER SERVICES*TE*8006434845~LE*2120~EB*R*IND*30~REF*18*2GC4GV1EG94~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*45*542566130~GE*1*542566130~IEA*1*542566130~