Raw X12 — CIN VR74554A

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260726*1715*|*00501*086105286*1*P*:~GS*HS*00ND*EMEDNYREL*20260726*1715*105286*X*005010X279A1~ST*270*5286*005010X279A1~BHT*0022*13*202607261715000001*20260726*1715~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*202607261715000001*00000000ND~NM1*IL*1******MI*VR74554A~EQ*30~DTP*291*D8*20260726~SE*13*5286~GE*1*105286~IEA*1*086105286~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260726*1315*^*00501*269492230*0*P*|~GS*HB*EMEDNYREL*00ND*20260726*131501*269492230*X*005010X279A1~ST*271*269492230*005010X279A1~BHT*0022*11*202607261715000001*20260726*131501~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*202607261715000001*00000000ND~NM1*IL*1*BLAND*SAMUEL****MI*VR74554A~N3*800 MADISON STREET            M123~N4*BROOKLYN*NY*11221~DMG*D8*19590623*M~DTP*472*D8*20260726~DTP*346*D8*20260701~DTP*102*D8*20260201~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=06~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*H4868~LS*2120~NM1*P4*2*WELLCARE*****PI*H4868~N3*PO BOX 25885~N4*TAMPA*FL*33622~PER*IC*PROVIDER SERVICES*TE*8002785155~LE*2120~EB*R*IND*30~REF*18*8Y53ER8RP85~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*43*269492230~GE*1*269492230~IEA*1*269492230~