Raw X12 — CIN VD77215E

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1926*|*00501*649192965*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1926*192965*X*005010X279A1~ST*270*2965*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*VD77215E~EQ*30~DTP*291*D8*20260814~SE*13*2965~GE*1*192965~IEA*1*649192965~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1526*^*00501*542613430*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152628*542613430*X*005010X279A1~ST*271*542613430*005010X279A1~BHT*0022*11*202608131926000001*20260813*152628~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*GARZON*JOSE****MI*VD77215E~N3*70       BARUCH DR            6D~N4*NEW YORK*NY*10002~DMG*D8*19490416*M~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260301~EB*1*IND*30**Community Coverage w/CBLTC~MSG*CF~MSG*PD~MSG*60~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=05~EB*B*IND*30***29*0~EB*1*IND*1~EB*1*IND*4~EB*1*IND*5~EB*1*IND*33~EB*1*IND*35~EB*1*IND*47~EB*1*IND*48~EB*1*IND*50~EB*1*IND*86~EB*1*IND*88~EB*1*IND*98~EB*1*IND*AG~EB*1*IND*AL~EB*1*IND*MH~EB*1*IND*UC~EB*R*IND*30~REF*18*NYCK90299030~REF*6P*157158002R~LS*2120~NM1*P4*2*GROUP HEALTH INC.*****PI*06~N3*2 WALL ST~N4*ALBANY*NY*122053828~PER*IC*PROVIDER SERVICES*TE*8006242414~LE*2120~EB*R*IND*30~REF*18*V70105109~REF*6P*1731319~LS*2120~NM1*P4*2*UNITED HEALTH CARE (DENTAL)*****PI*F7D~N3*PO BOX 30560~N4*BETHESDA*MD*208240560~PER*IC*PROVIDER SERVICES*TE*8668776187~LE*2120~EB*R*IND*30~REF*6P*H5549~LS*2120~NM1*P4*2*VNS CHOICE MEDICARE*****PI*H5549~N3*1250 BROADWAY  3RD FLOOR~N4*NEW YORK*NY*10001~PER*IC*PROVIDER SERVICES*TE*8665976674~LE*2120~EB*R*IND*30~REF*18*1W17F61AM49~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*71*542613430~GE*1*542613430~IEA*1*542613430~