Raw X12 — CIN SB51269E

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0705*|*00501*518303298*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0705*303298*X*005010X279A1~ST*270*3298*005010X279A1~BHT*0022*13*202608120705000001*20260812*0705~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*202608120705000001*00000000ND~NM1*IL*1******MI*SB51269E~EQ*30~DTP*291*D8*20260812~SE*13*3298~GE*1*303298~IEA*1*518303298~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0304*^*00501*166479330*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030458*166479330*X*005010X279A1~ST*271*166479330*005010X279A1~BHT*0022*11*202608120705000001*20260812*030458~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*202608120705000001*00000000ND~NM1*IL*1*AKSELRUD*VALERY****MI*SB51269E~N3*497 BEDFORD AVENUE~N4*STATEN ISLAND*NY*10306~DMG*D8*19530712*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~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*2M21CU7JR04~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*35*166479330~GE*1*166479330~IEA*1*166479330~