Raw X12 — CIN XH37634W

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1948*|*00501*304889636*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1948*889636*X*005010X279A1~ST*270*9636*005010X279A1~BHT*0022*13*202608091948000001*20260809*1948~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*202608091948000001*00000000ND~NM1*IL*1******MI*XH37634W~EQ*30~DTP*291*D8*20260806~SE*13*9636~GE*1*889636~IEA*1*304889636~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1548*^*00501*312000930*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*154805*312000930*X*005010X279A1~ST*271*312000930*005010X279A1~BHT*0022*11*202608091948000001*20260809*154805~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*202608091948000001*00000000ND~NM1*IL*1*GOLDENBERG*ENRIETA****MI*XH37634W~N3*915 EAST 7 STREET             6C~N4*BROOKLYN*NY*11230~DMG*D8*19461030*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260401~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=03~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*INTERBOROUGH DEV/CONSULT CTRS*****XX*1588611842~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*SOUTHWEST BROOKLYN HEALTH HOME LLC*****XX*1023354933~LE*2120~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*4TR4KF6JM81~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*53*312000930~GE*1*312000930~IEA*1*312000930~