Raw X12 — CIN WD22516Y

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1955*|*00501*305322861*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1955*322861*X*005010X279A1~ST*270*2861*005010X279A1~BHT*0022*13*202608091955000001*20260809*1955~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*202608091955000001*00000000ND~NM1*IL*1******MI*WD22516Y~EQ*30~DTP*291*D8*20260806~SE*13*2861~GE*1*322861~IEA*1*305322861~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1555*^*00501*315083130*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*155518*315083130*X*005010X279A1~ST*271*315083130*005010X279A1~BHT*0022*11*202608091955000001*20260809*155518~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*202608091955000001*00000000ND~NM1*IL*1*SAKOVICH*MINA****MI*WD22516Y~N3*2800 COYLE STREET             320~N4*BROOKLYN*NY*11235~DMG*D8*19480525*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20251101~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=02~LS*2120~NM1*Y2*2*ELDERSERVE HEALTH INC MLTCP*****PI*EH~N3*80 W 225TH ST FL 3~N4*BRONX*NY*104637002~PER*IC*PROVIDER SERVICES*TE*8003703600~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*1*IND*88~EB*R*IND*30~REF*18*106803549   W~LS*2120~NM1*P4*2*ANTHEM BC/BS (EMPIRE)*****PI*12~N3*PO BOX 1407 CHURCH ST STATION*ATTN  CLAIMS DEPT~N4*NEW YORK*NY*100081407~PER*IC*PROVIDER SERVICES*TE*8005235978~LE*2120~EB*R*IND*30~REF*18*2XJ4JR9RM04~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*42*315083130~GE*1*315083130~IEA*1*315083130~