Raw X12 — CIN WH79641P

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1927*|*00501*649231412*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1927*231412*X*005010X279A1~ST*270*1412*005010X279A1~BHT*0022*13*202608131927000001*20260813*1927~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*202608131927000001*00000000ND~NM1*IL*1******MI*WH79641P~EQ*30~DTP*291*D8*20260814~SE*13*1412~GE*1*231412~IEA*1*649231412~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1527*^*00501*542776430*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*152706*542776430*X*005010X279A1~ST*271*542776430*005010X279A1~BHT*0022*11*202608131927000001*20260813*152706~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*202608131927000001*00000000ND~NM1*IL*1*VILLALBA*ALBA****MI*WH79641P~N3*1912     H AVE                3C~N4*BROOKLYN*NY*11230~DMG*D8*19400421*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=10~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*18*00000013178~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*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*8N52CV6HA84~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*52*542776430~GE*1*542776430~IEA*1*542776430~