Raw X12 — CIN XJ83951U

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1926*|*00501*649200188*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1926*200188*X*005010X279A1~ST*270*0188*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*XJ83951U~EQ*30~DTP*291*D8*20260814~SE*13*0188~GE*1*200188~IEA*1*649200188~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1526*^*00501*542641230*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152635*542641230*X*005010X279A1~ST*271*542641230*005010X279A1~BHT*0022*11*202608131926000001*20260813*152635~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*LEE*MARY*A***MI*XJ83951U~N3*185 NEVINS ST                 3A~N4*BROOKLYN*NY*11217~DMG*D8*19500221*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20251101~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~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*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*8XW0RF0RJ23~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*542641230~GE*1*542641230~IEA*1*542641230~