Raw X12 — CIN UM57198U

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260914*1121*|*00501*384866074*1*P*:~GS*HS*00ND*EMEDNYREL*20260914*1121*866074*X*005010X279A1~ST*270*6074*005010X279A1~BHT*0022*13*202609141121000001*20260914*1121~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*202609141121000001*00000000ND~NM1*IL*1******MI*UM57198U~EQ*30~DTP*291*D8*20260914~SE*13*6074~GE*1*866074~IEA*1*384866074~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260914*0721*^*00501*245192030*0*P*|~GS*HB*EMEDNYREL*00ND*20260914*072106*245192030*X*005010X279A1~ST*271*245192030*005010X279A1~BHT*0022*11*202609141121000001*20260914*072106~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*202609141121000001*00000000ND~NM1*IL*1*MANTUANO*VIVIANA*A***MI*UM57198U~N3*80-61    161ST ST             1~N4*JAMAICA*NY*11432~DMG*D8*19461220*F~DTP*472*D8*20260914~DTP*346*D8*20260901~DTP*102*D8*20260401~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*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*4HP1HA7AM20~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*44*245192030~GE*1*245192030~IEA*1*245192030~