Raw X12 — CIN XQ66165V

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1946*|*00501*304771267*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1946*771267*X*005010X279A1~ST*270*1267*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*XQ66165V~EQ*30~DTP*291*D8*20260806~SE*13*1267~GE*1*771267~IEA*1*304771267~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1546*^*00501*311927930*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*154607*311927930*X*005010X279A1~ST*271*311927930*005010X279A1~BHT*0022*11*202608091946000001*20260809*154607~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*CHKHEIDZE*SHOTA****MI*XQ66165V~N3*248-65   248-65 THORNHILL AVEN~N4*LITTLE NECK*NY*11362~DMG*D8*19381107*M~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20251101~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*PD~MSG*CNTY CD=66 054~MSG*RECERT MONTH=12~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*W*IND*CQ~LS*2120~NM1*Y2*2*NORTH SHORE UNIVERSITY HOSPITAL*****XX*1932472107~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*NORTH SHORE UNIVERSITY HOSPITAL*****XX*1932472107~LE*2120~SE*41*311927930~GE*1*311927930~IEA*1*311927930~