Raw X12 — CIN YT50689A

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260809*1958*|*00501*305494055*1*P*:~GS*HS*00ND*EMEDNYREL*20260809*1958*494055*X*005010X279A1~ST*270*4055*005010X279A1~BHT*0022*13*202608091958000001*20260809*1958~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*202608091958000001*00000000ND~NM1*IL*1******MI*YT50689A~EQ*30~DTP*291*D8*20260806~SE*13*4055~GE*1*494055~IEA*1*305494055~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260809*1558*^*00501*315200230*0*P*|~GS*HB*EMEDNYREL*00ND*20260809*155809*315200230*X*005010X279A1~ST*271*315200230*005010X279A1~BHT*0022*11*202608091958000001*20260809*155809~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*202608091958000001*00000000ND~NM1*IL*1*WILSON*GILBERT****MI*YT50689A~N3*125 BEACH 19TH STREET         21G~N4*FAR ROCKAWAY*NY*11691~DMG*D8*19590315*M~DTP*472*D8*20260809~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=12~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*NEW YORK PSYCHOT AND COUNS CT*****XX*1902811342~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*COORDINATED BEHAVIORAL CARE INC*****XX*1730451071~LE*2120~EB*R*IND*30~REF*6P*H4868~LS*2120~NM1*P4*2*WELLCARE*****PI*H4868~N3*PO BOX 25885~N4*TAMPA*FL*33622~PER*IC*PROVIDER SERVICES*TE*8002785155~LE*2120~EB*R*IND*30~REF*18*5FA8FM6ET53~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*53*315200230~GE*1*315200230~IEA*1*315200230~