Raw X12 — CIN VZ33091H

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1944*|*00501*304673161*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1944*673161*X*005010X279A1~ST*270*3161*005010X279A1~BHT*0022*13*202608091944000001*20260809*1944~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*202608091944000001*00000000ND~NM1*IL*1******MI*VZ33091H~EQ*30~DTP*291*D8*20260806~SE*13*3161~GE*1*673161~IEA*1*304673161~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1544*^*00501*311874230*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*154428*311874230*X*005010X279A1~ST*271*311874230*005010X279A1~BHT*0022*11*202608091944000001*20260809*154428~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*202608091944000001*00000000ND~NM1*IL*1*ARIASACEVEDO*JUANA****MI*VZ33091H~N3*1373     PACIFIC ST           2~N4*BROOKLYN*NY*11216~DMG*D8*19610127*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260201~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=08~LS*2120~NM1*Y2*2*ANTHEM HP LLC PARTIAL MLTC*****PI*KX~N3*ONE PENN PLZ FL 35~N4*NEW YORK*NY*101190000~PER*IC*PROVIDER SERVICES*TE*2125635570~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*1*IND*88~SE*29*311874230~GE*1*311874230~IEA*1*311874230~