Raw X12 — CIN VC10551V

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260914*1119*|*00501*384749972*1*P*:~GS*HS*00ND*EMEDNYREL*20260914*1119*749972*X*005010X279A1~ST*270*9972*005010X279A1~BHT*0022*13*202609141119000001*20260914*1119~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*202609141119000001*00000000ND~NM1*IL*1******MI*VC10551V~EQ*30~DTP*291*D8*20260914~SE*13*9972~GE*1*749972~IEA*1*384749972~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260914*0719*^*00501*244128730*0*P*|~GS*HB*EMEDNYREL*00ND*20260914*071910*244128730*X*005010X279A1~ST*271*244128730*005010X279A1~BHT*0022*11*202609141119000001*20260914*071910~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*202609141119000001*00000000ND~NM1*IL*1*LAGUER*LIZ****MI*VC10551V~N3*309 MACDOUGAL ST              14F~N4*BROOKLYN*NY*11233~DMG*D8*19770805*F~DTP*472*D8*20260914~DTP*346*D8*20260901~DTP*102*D8*20260801~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*H9~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=10~LS*2120~NM1*Y2*2*ELDERPLAN INC MAP*****PI*YL~N3*55 WATER ST FL 46~N4*NEW YORK*NY*100413211~PER*IC*PROVIDER SERVICES*TE*8778916447~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*W*IND*CQ~LS*2120~NM1*Y2*2*ESSEN MEDICAL ASSOCIATES PC*****XX*1366418709~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*SRH CHN LEAD HEALTH HOME LLC*****XX*1750053948~LE*2120~EB*R*IND*30~REF*6P*H3347~LS*2120~NM1*P4*2*ELDERPLAN*****PI*H3347~N3*ELDERPLAN  INC   745 64TH STREET~N4*BROOKLYN*NY*11220~PER*IC*PROVIDER SERVICES*TE*8003533765~LE*2120~EB*R*IND*30~REF*18*8C88VG5VF61~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*54*244128730~GE*1*244128730~IEA*1*244128730~