Raw X12 — CIN VT11614F

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1947*|*00501*304820314*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1947*820314*X*005010X279A1~ST*270*0314*005010X279A1~BHT*0022*13*202608091947000001*20260809*1947~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*202608091947000001*00000000ND~NM1*IL*1******MI*VT11614F~EQ*30~DTP*291*D8*20260806~SE*13*0314~GE*1*820314~IEA*1*304820314~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1546*^*00501*311954630*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*154656*311954630*X*005010X279A1~ST*271*311954630*005010X279A1~BHT*0022*11*202608091947000001*20260809*154656~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*202608091947000001*00000000ND~NM1*IL*1*ENRIQUEZ*NUBIA****MI*VT11614F~N3*41-31    51 ST                2B~N4*QNS*NY*11377~DMG*D8*19560109*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20251201~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=09~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*18*104646998   UAA~LS*2120~NM1*P4*2*ANTHEM BC/BS (EMPIRE)*****PI*12~N3*PO BOX 1407 CHURCH STREET STATION~N4*NEW YORK*NY*100081407~PER*IC*PROVIDER SERVICES*TE*8005235978~LE*2120~EB*R*IND*30~REF*6P*H3359~LS*2120~NM1*P4*2*HEALTHFIRST MEDICARE PLAN*****PI*H3359~N3*HEALTHFIRST MEDICARE PLAN  PO BOX 5165~N4*NEW YORK*NY*10274~PER*IC*PROVIDER SERVICES*TE*8882601010~LE*2120~EB*R*IND*30~REF*18*5M03PR8QN19~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*50*311954630~GE*1*311954630~IEA*1*311954630~