Raw X12 — CIN WA22236Z

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260810*1037*|*00501*358222983*1*P*:~GS*HS*00ND*EMEDNYREL*20260810*1037*222983*X*005010X279A1~ST*270*2983*005010X279A1~BHT*0022*13*202608101037000001*20260810*1037~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*202608101037000001*00000000ND~NM1*IL*1******MI*WA22236Z~EQ*30~DTP*291*D8*20260806~SE*13*2983~GE*1*222983~IEA*1*358222983~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260810*0636*^*00501*238437130*0*P*|~GS*HB*EMEDNYREL*00ND*20260810*063658*238437130*X*005010X279A1~ST*271*238437130*005010X279A1~BHT*0022*11*202608101037000001*20260810*063658~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*202608101037000001*00000000ND~NM1*IL*1*SEREBRYANYY*EDUARD****MI*WA22236Z~N3*2685 HOMECREST AVE            5F~N4*BROOKLYN*NY*11235~DMG*D8*19431110*M~DTP*472*D8*20260810~DTP*346*D8*20260801~DTP*102*D8*20260401~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~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*W*IND*CQ~LS*2120~NM1*Y2*2*ST VINCENTS SERVICES*****XX*1003015694~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*SRH CHN LEAD HEALTH HOME LLC*****XX*1750053948~LE*2120~EB*R*IND*30~REF*18*6RF7N91JH49~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*44*238437130~GE*1*238437130~IEA*1*238437130~