Raw X12 — CIN KS04754J

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1957*|*00501*305450015*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1957*450015*X*005010X279A1~ST*270*0015*005010X279A1~BHT*0022*13*202608091957000001*20260809*1957~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*202608091957000001*00000000ND~NM1*IL*1******MI*KS04754J~EQ*30~DTP*291*D8*20260806~SE*13*0015~GE*1*450015~IEA*1*305450015~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1557*^*00501*315172830*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*155725*315172830*X*005010X279A1~ST*271*315172830*005010X279A1~BHT*0022*11*202608091957000001*20260809*155725~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*202608091957000001*00000000ND~NM1*IL*1*TSOGLIN*EUGENYA****MI*KS04754J~N3*2483     W 16 ST              9G~N4*BKLYN*NY*11214~DMG*D8*19470429*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=07~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*1J34G72GJ89~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*34*315172830~GE*1*315172830~IEA*1*315172830~