Raw X12 — CIN TS27570F

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1948*|*00501*304924424*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1948*924424*X*005010X279A1~ST*270*4424*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*TS27570F~EQ*30~DTP*291*D8*20260806~SE*13*4424~GE*1*924424~IEA*1*304924424~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1548*^*00501*312024230*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*154840*312024230*X*005010X279A1~ST*271*312024230*005010X279A1~BHT*0022*11*202608091948000001*20260809*154840~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*HANYSH*HALYNA****MI*TS27570F~N3*2682     W 2ND ST             3H~N4*BROOKLYN*NY*11223~DMG*D8*19500813*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 063~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~SE*28*312024230~GE*1*312024230~IEA*1*312024230~