Raw X12 — CIN ZV42162Q

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1025*|*00501*357513672*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1025*513672*X*005010X279A1~ST*270*3672*005010X279A1~BHT*0022*13*202608101025000001*20260810*1025~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*202608101025000001*00000000ND~NM1*IL*1******MI*ZV42162Q~EQ*30~DTP*291*D8*20260806~SE*13*3672~GE*1*513672~IEA*1*357513672~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0625*^*00501*237497030*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*062509*237497030*X*005010X279A1~ST*271*237497030*005010X279A1~BHT*0022*11*202608101025000001*20260810*062509~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*202608101025000001*00000000ND~NM1*IL*1*GARDNER*JOHN****MI*ZV42162Q~N3*721      WILLOUGHBY AVENUE    3N~N4*BROOKLYN*NY*11206~DMG*D8*19530606*M~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=10~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*H3387~LS*2120~NM1*P4*2*UNITEDHEALTHCARE DUAL COMPLETE*****PI*H3387~N3*P O BOX 917~N4*NEW YORK*NY*10269~PER*IC*PROVIDER SERVICES*TE*8005144912~LE*2120~EB*R*IND*30~REF*18*2QW4AQ6PJ92~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*237497030~GE*1*237497030~IEA*1*237497030~