Raw X12 — CIN NW97877P

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1022*|*00501*357327958*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1022*327958*X*005010X279A1~ST*270*7958*005010X279A1~BHT*0022*13*202608101022000001*20260810*1022~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*202608101022000001*00000000ND~NM1*IL*1******MI*NW97877P~EQ*30~DTP*291*D8*20260806~SE*13*7958~GE*1*327958~IEA*1*357327958~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0622*^*00501*237202430*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*062203*237202430*X*005010X279A1~ST*271*237202430*005010X279A1~BHT*0022*11*202608101022000001*20260810*062203~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*202608101022000001*00000000ND~NM1*IL*1*ANDREEVA*IRINA*V***MI*NW97877P~N3*79       BRIGHTON 11 ST       3C~N4*BROOKLYN*NY*11235~DMG*D8*19571222*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20260301~EB*U*IND*30**ELIGIBLE PCP~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*R*IND*30~REF*18*2GC5P22DF83~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*34*237202430~GE*1*237202430~IEA*1*237202430~