Raw X12 — CIN SU83185M

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260914*1120*|*00501*384819034*1*P*:~GS*HS*00ND*EMEDNYREL*20260914*1120*819034*X*005010X279A1~ST*270*9034*005010X279A1~BHT*0022*13*202609141120000001*20260914*1120~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*202609141120000001*00000000ND~NM1*IL*1******MI*SU83185M~EQ*30~DTP*291*D8*20260914~SE*13*9034~GE*1*819034~IEA*1*384819034~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260914*0720*^*00501*244428030*0*P*|~GS*HB*EMEDNYREL*00ND*20260914*072019*244428030*X*005010X279A1~ST*271*244428030*005010X279A1~BHT*0022*11*202609141120000001*20260914*072019~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*202609141120000001*00000000ND~NM1*IL*1*MOTA*RAMON****MI*SU83185M~N3*261 EAST 202ND STREET         1M~N4*BRONX*NY*10458~DMG*D8*19550219*M~DTP*472*D8*20260914~DTP*346*D8*20260901~DTP*102*D8*20260701~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*PD~MSG*CNTY CD=66 544~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*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*MONTEFIORE MEDICAL CENTER*****XX*1831461847~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*3N39Y63EV10~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*53*244428030~GE*1*244428030~IEA*1*244428030~