Raw X12 — CIN TF72214H

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1024*|*00501*357479850*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1024*479850*X*005010X279A1~ST*270*9850*005010X279A1~BHT*0022*13*202608101024000001*20260810*1024~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*202608101024000001*00000000ND~NM1*IL*1******MI*TF72214H~EQ*30~DTP*291*D8*20260806~SE*13*9850~GE*1*479850~IEA*1*357479850~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0624*^*00501*237435230*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*062435*237435230*X*005010X279A1~ST*271*237435230*005010X279A1~BHT*0022*11*202608101024000001*20260810*062435~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*202608101024000001*00000000ND~NM1*IL*1*FERNANDEZ*JOSE*M***MI*TF72214H~N3*300 GRANT AVE~N4*BROOKLYN*NY*11208~DMG*D8*19621114*M~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20251201~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~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*6P*H3359~LS*2120~NM1*P4*2*HEALTHFIRST MEDICARE PLAN*****PI*H3359~N3*HEALTHFIRST MEDICARE PLAN  PO BOX 5165~N4*NEW YORK*NY*10274~PER*IC*PROVIDER SERVICES*TE*8882601010~LE*2120~EB*R*IND*30~REF*18*1N85V15EP50~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*237435230~GE*1*237435230~IEA*1*237435230~