Raw X12 — CIN VV72460V

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1926*|*00501*649204828*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1926*204828*X*005010X279A1~ST*270*4828*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*VV72460V~EQ*30~DTP*291*D8*20260814~SE*13*4828~GE*1*204828~IEA*1*649204828~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1526*^*00501*542661830*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152640*542661830*X*005010X279A1~ST*271*542661830*005010X279A1~BHT*0022*11*202608131926000001*20260813*152640~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*MCPHERSON*DEBORAH****MI*VV72460V~N3*4523     AVENUE M~N4*BROOKLYN*NY*11234~DMG*D8*19520401*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260201~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=03~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*18*00000014205~REF*6P*ICA001~LS*2120~NM1*P4*2*DAVIS VISION*****PI*90~N3*PO BOX 1501~N4*LATHAM*NY*121108001~PER*IC*PROVIDER SERVICES*TE*8009995431~LE*2120~EB*R*IND*30~REF*6P*H3359~LS*2120~NM1*P4*2*HEALTHFIRST MEDICARE PLAN*****PI*H3359~N3*HEALTHFIRST MEDICARE PLAN  PO BOX 5165~N4*NEW YORK*NY*10274~PER*IC*PROVIDER SERVICES*TE*8882601010~LE*2120~EB*R*IND*30~REF*18*1F34RV7MW79~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*53*542661830~GE*1*542661830~IEA*1*542661830~