Raw X12 — CIN TB36951J

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260914*1117*|*00501*384662976*1*P*:~GS*HS*00ND*EMEDNYREL*20260914*1117*662976*X*005010X279A1~ST*270*2976*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*TB36951J~EQ*30~DTP*291*D8*20260914~SE*13*2976~GE*1*662976~IEA*1*384662976~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260914*0717*^*00501*244015630*0*P*|~GS*HB*EMEDNYREL*00ND*20260914*071743*244015630*X*005010X279A1~ST*271*244015630*005010X279A1~BHT*0022*11*202609141117000001*20260914*071743~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*CASTILLO*CLEMENTE****MI*TB36951J~N3*38       BUSH  STREET         2B~N4*BROOKLYN*NY*11231~DMG*D8*19370123*M~DTP*472*D8*20260914~DTP*346*D8*20260901~DTP*102*D8*20251001~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*H3312~LS*2120~NM1*P4*2*AETNA MEDICARE*****PI*H3312~N3*151 FARMINGTON AVENUE~N4*HARTFORD*CT*06156~PER*IC*PROVIDER SERVICES*TE*8002825366~LE*2120~EB*R*IND*30~REF*18*7FA0DT2AC39~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*44*244015630~GE*1*244015630~IEA*1*244015630~