Raw X12 — CIN QE67712D

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1957*|*00501*305455012*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1957*455012*X*005010X279A1~ST*270*5012*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*QE67712D~EQ*30~DTP*291*D8*20260806~SE*13*5012~GE*1*455012~IEA*1*305455012~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1557*^*00501*315175630*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*155730*315175630*X*005010X279A1~ST*271*315175630*005010X279A1~BHT*0022*11*202608091957000001*20260809*155730~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*TUMANSKAYA*LYUBOV****MI*QE67712D~N3*824 EAST 9TH STREET           3N~N4*BROOKLYN*NY*11230~DMG*D8*19370609*F~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20260501~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~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*W*IND*CQ~LS*2120~NM1*Y2*2*VRD GROUP CORP*****XX*1891453569~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*SRH CHN LEAD HEALTH HOME LLC*****XX*1750053948~LE*2120~EB*R*IND*30~REF*18*00000013865~REF*6P*ICA001~LS*2120~NM1*P4*2*DAVIS VISION*****PI*90~N3*PO BOX 1501~N4*LATHAM*NY*121108001~PER*IC*PROVIDER SERVICES*TE*8009995431~LE*2120~EB*R*IND*30~REF*18*9A19AN8FJ27~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*54*315175630~GE*1*315175630~IEA*1*315175630~