Raw X12 — CIN ST52366S

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1949*|*00501*304967477*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1949*967477*X*005010X279A1~ST*270*7477*005010X279A1~BHT*0022*13*202608091949000001*20260809*1949~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*202608091949000001*00000000ND~NM1*IL*1******MI*ST52366S~EQ*30~DTP*291*D8*20260806~SE*13*7477~GE*1*967477~IEA*1*304967477~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1549*^*00501*312052630*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*154923*312052630*X*005010X279A1~ST*271*312052630*005010X279A1~BHT*0022*11*202608091949000001*20260809*154923~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*202608091949000001*00000000ND~NM1*IL*1*KAPARA*DORIT****MI*ST52366S~N3*1253     E 69TH ST~N4*BROOKLYN*NY*11234~DMG*D8*19670715*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260801~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=02~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*8VW7U77FG51~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*35*312052630~GE*1*312052630~IEA*1*312052630~