Raw X12 — CIN VD45258V

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1926*|*00501*649201471*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1926*201471*X*005010X279A1~ST*270*1471*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*VD45258V~EQ*30~DTP*291*D8*20260814~SE*13*1471~GE*1*201471~IEA*1*649201471~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1526*^*00501*542647030*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152637*542647030*X*005010X279A1~ST*271*542647030*005010X279A1~BHT*0022*11*202608131926000001*20260813*152637~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*LEON*LUIS*A***MI*VD45258V~N3*553      GRAHAM AVENUE        1~N4*BROOKLYN*NY*11222~DMG*D8*19451208*M~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260301~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=11~LS*2120~NM1*Y2*2*VNS CHOICE PLUS M/M MAP*****PI*YN~N3*220 E 42ND ST FL 6~N4*NEW YORK*NY*100175831~PER*IC*PROVIDER SERVICES*TE*8669867691~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~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*1KC1CQ2DW97~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*542647030~GE*1*542647030~IEA*1*542647030~