Raw X12 — CIN PA61255V

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1036*|*00501*358171410*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1036*171410*X*005010X279A1~ST*270*1410*005010X279A1~BHT*0022*13*202608101036000001*20260810*1036~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*202608101036000001*00000000ND~NM1*IL*1******MI*PA61255V~EQ*30~DTP*291*D8*20260806~SE*13*1410~GE*1*171410~IEA*1*358171410~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0636*^*00501*238388430*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*063607*238388430*X*005010X279A1~ST*271*238388430*005010X279A1~BHT*0022*11*202608101036000001*20260810*063607~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*202608101036000001*00000000ND~NM1*IL*1*ZAKHARCHENKO*LIDIA****MI*PA61255V~N3*2780     W 5 ST               23E~N4*BROOKLYN*NY*11224~DMG*D8*19370527*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20251101~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*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*6QV3RA4HE78~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*238388430~GE*1*238388430~IEA*1*238388430~