Raw X12 — CIN RW10831B

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260726*1650*|*00501*084608346*1*P*:~GS*HS*00ND*EMEDNYREL*20260726*1650*608346*X*005010X279A1~ST*270*8346*005010X279A1~BHT*0022*13*202607261650000001*20260726*1650~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*202607261650000001*00000000ND~NM1*IL*1******MI*RW10831B~EQ*30~DTP*291*D8*20260726~SE*13*8346~GE*1*608346~IEA*1*084608346~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260726*1250*^*00501*264937830*0*P*|~GS*HB*EMEDNYREL*00ND*20260726*125005*264937830*X*005010X279A1~ST*271*264937830*005010X279A1~BHT*0022*11*202607261650000001*20260726*125005~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*202607261650000001*00000000ND~NM1*IL*1*OSEGUERA*JOSEFINA****MI*RW10831B~N3*1122 RHINELANDER AVE~N4*BRONX*NY*10461~DMG*D8*19760718*F~DTP*472*D8*20260726~DTP*346*D8*20260701~DTP*102*D8*20250801~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 H78~MSG*RECERT MONTH=12~LS*2120~NM1*Y2*2*ANTHEM HP LLC MAINSTREAM*****PI*KP~N3*1 PENN PLZ FL 35~N4*NEW YORK*NY*101193601~PER*IC*PROVIDER SERVICES*TE*2125635570~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*1*IND*88~SE*29*264937830~GE*1*264937830~IEA*1*264937830~