Raw X12 — CIN SX87037J

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1946*|*00501*304809569*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1946*809569*X*005010X279A1~ST*270*9569*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*SX87037J~EQ*30~DTP*291*D8*20260806~SE*13*9569~GE*1*809569~IEA*1*304809569~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1546*^*00501*311947730*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*154645*311947730*X*005010X279A1~ST*271*311947730*005010X279A1~BHT*0022*11*202608091946000001*20260809*154645~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*DURAN*JOSEFINA****MI*SX87037J~N3*9722     ALBERT ROAD          1FL~N4*OZONE PARK*NY*11417~DMG*D8*19541104*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260401~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CNTY CD=66 5H9~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~EB*R*IND*30~REF*6P*H3387~LS*2120~NM1*P4*2*UNITEDHEALTHCARE DUAL COMPLETE*****PI*H3387~N3*P O BOX 917~N4*NEW YORK*NY*10269~PER*IC*PROVIDER SERVICES*TE*8005144912~LE*2120~EB*R*IND*30~REF*18*7FX3JD7WM06~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*51*311947730~GE*1*311947730~IEA*1*311947730~