Raw X12 — CIN RY18760W

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260914*1117*|*00501*384650964*1*P*:~GS*HS*00ND*EMEDNYREL*20260914*1117*650964*X*005010X279A1~ST*270*0964*005010X279A1~BHT*0022*13*202609141117000001*20260914*1117~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*202609141117000001*00000000ND~NM1*IL*1******MI*RY18760W~EQ*30~DTP*291*D8*20260914~SE*13*0964~GE*1*650964~IEA*1*384650964~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260914*0717*^*00501*243998930*0*P*|~GS*HB*EMEDNYREL*00ND*20260914*071731*243998930*X*005010X279A1~ST*271*243998930*005010X279A1~BHT*0022*11*202609141117000001*20260914*071731~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*202609141117000001*00000000ND~NM1*IL*1*JEEUTH*BELLA****MI*RY18760W~N3*2233 ELLIS AVE                1A~N4*BRONX*NY*10462~DMG*D8*19540521*F~DTP*472*D8*20260914~DTP*346*D8*20260901~DTP*102*D8*20260301~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=10~LS*2120~NM1*Y2*2*VILLAGE SENIOR SVC CORP PARTIAL LTC*****PI*VL~N3*112 CHARLES ST FL 2~N4*NEW YORK*NY*100142653~PER*IC*PROVIDER SERVICES*TE*8557692500~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*1*IND*88~EB*R*IND*30~REF*6P*H4868~LS*2120~NM1*P4*2*WELLCARE*****PI*H4868~N3*PO BOX 25885~N4*TAMPA*FL*33622~PER*IC*PROVIDER SERVICES*TE*8002785155~LE*2120~EB*R*IND*30~REF*18*8GD8U81UH66~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*44*243998930~GE*1*243998930~IEA*1*243998930~