Raw X12 — CIN SY12167Y

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1036*|*00501*358175414*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1036*175414*X*005010X279A1~ST*270*5414*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*SY12167Y~EQ*30~DTP*291*D8*20260806~SE*13*5414~GE*1*175414~IEA*1*358175414~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0636*^*00501*238392630*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*063611*238392630*X*005010X279A1~ST*271*238392630*005010X279A1~BHT*0022*11*202608101036000001*20260810*063611~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*ZAMYATINA*LUDMILA****MI*SY12167Y~N3*1739     63RD ST              4A~N4*BROOKLYN*NY*11204~DMG*D8*19510803*F~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20260401~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~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~EB*R*IND*30~REF*18*SY12167Y~LS*2120~NM1*P4*2*LOCAL 1199 SEIU HC*****PI*LOHC~N3*PO BOX 1007 TIMES SQUARE STATION~N4*NEW YORK*NY*101081007~PER*IC*PROVIDER SERVICES*TE*6464739200~LE*2120~EB*R*IND*30~REF*6P*H8432~LS*2120~NM1*P4*2*EMPIRE MEDIBLUE CORE*****PI*H8432~N3*EMPIRE MEDIBLUE*PO BOX 1407 CHURCH STREET STATION~N4*NEW YORK*NY*100081407~PER*IC*PROVIDER SERVICES*TE*8557311090~LE*2120~EB*R*IND*30~REF*18*5KQ2C31AG96~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*50*238392630~GE*1*238392630~IEA*1*238392630~