Raw X12 — CIN QE95698V

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1027*|*00501*357648825*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1027*648825*X*005010X279A1~ST*270*8825*005010X279A1~BHT*0022*13*202608101027000001*20260810*1027~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*202608101027000001*00000000ND~NM1*IL*1******MI*QE95698V~EQ*30~DTP*291*D8*20260806~SE*13*8825~GE*1*648825~IEA*1*357648825~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0627*^*00501*237689230*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*062724*237689230*X*005010X279A1~ST*271*237689230*005010X279A1~BHT*0022*11*202608101027000001*20260810*062724~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*202608101027000001*00000000ND~NM1*IL*1*KIM*AGAFYA****MI*QE95698V~N3*2060     OCEAN AVE            5G~N4*BROOKLYN*NY*11230~DMG*D8*19390119*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20260501~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*7X80N12YE49~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*34*237689230~GE*1*237689230~IEA*1*237689230~