Raw X12 — CIN PW09176R

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1033*|*00501*357998229*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1033*998229*X*005010X279A1~ST*270*8229*005010X279A1~BHT*0022*13*202608101033000001*20260810*1033~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*202608101033000001*00000000ND~NM1*IL*1******MI*PW09176R~EQ*30~DTP*291*D8*20260806~SE*13*8229~GE*1*998229~IEA*1*357998229~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0633*^*00501*238210330*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*063313*238210330*X*005010X279A1~ST*271*238210330*005010X279A1~BHT*0022*11*202608101033000001*20260810*063313~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*202608101033000001*00000000ND~NM1*IL*1*SEMYONOVA*IRINA****MI*PW09176R~N3*6707      YELLOWSTONE BLVD    1H~N4*FOREST HILLS*NY*11375~DMG*D8*19661001*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20260301~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=66 090~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~SE*30*238210330~GE*1*238210330~IEA*1*238210330~