Raw X12 — CIN UV21121S

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1946*|*00501*304767262*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1946*767262*X*005010X279A1~ST*270*7262*005010X279A1~BHT*0022*13*202608091946000001*20260809*1946~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*202608091946000001*00000000ND~NM1*IL*1******MI*UV21121S~EQ*30~DTP*291*D8*20260806~SE*13*7262~GE*1*767262~IEA*1*304767262~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1546*^*00501*311925930*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*154603*311925930*X*005010X279A1~ST*271*311925930*005010X279A1~BHT*0022*11*202608091946000001*20260809*154603~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*202608091946000001*00000000ND~NM1*IL*1*CHERTOG*BORIS****MI*UV21121S~N3*24 AMAGANSETT DR~N4*MORGANVILLE*NJ*07751~DMG*D8*19400517*M~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 523~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~EB*R*IND*30~REF*6P*H3312~LS*2120~NM1*P4*2*AETNA MEDICARE*****PI*H3312~N3*151 FARMINGTON AVENUE~N4*HARTFORD*CT*06156~PER*IC*PROVIDER SERVICES*TE*8002825366~LE*2120~EB*R*IND*30~REF*18*4A87UR4GC48~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*311925930~GE*1*311925930~IEA*1*311925930~