Raw X12 — CIN RF63311B

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260914*1119*|*00501*384782000*1*P*:~GS*HS*00ND*EMEDNYREL*20260914*1119*782000*X*005010X279A1~ST*270*2000*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*RF63311B~EQ*30~DTP*291*D8*20260914~SE*13*2000~GE*1*782000~IEA*1*384782000~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260914*0719*^*00501*244172730*0*P*|~GS*HB*EMEDNYREL*00ND*20260914*071942*244172730*X*005010X279A1~ST*271*244172730*005010X279A1~BHT*0022*11*202609141119000001*20260914*071942~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*GUALLPASAYAGO*MIGUEL****MI*RF63311B~N3*105-01   FARMERS BLVD         1~N4*SAINT ALBANS*NY*11412~DMG*D8*19370525*M~DTP*472*D8*20260914~DTP*346*D8*20260901~DTP*102*D8*20251001~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=10~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~SE*30*244172730~GE*1*244172730~IEA*1*244172730~