Raw X12 — CIN UZ48605D

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0705*|*00501*518323263*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0705*323263*X*005010X279A1~ST*270*3263*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*UZ48605D~EQ*30~DTP*291*D8*20260812~SE*13*3263~GE*1*323263~IEA*1*518323263~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0305*^*00501*167097830*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030518*167097830*X*005010X279A1~ST*271*167097830*005010X279A1~BHT*0022*11*202608120705000001*20260812*030518~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*AVGUST*YELENA*S***MI*UZ48605D~N3*414      ELMWOOD AVA          2A~N4*BROOKLYN*NY*11230~DMG*D8*19460325*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 533~MSG*RECERT MONTH=01~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*UZ48605D~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*H3359~LS*2120~NM1*P4*2*HEALTHFIRST MEDICARE PLAN*****PI*H3359~N3*HEALTHFIRST MEDICARE PLAN  PO BOX 5165~N4*NEW YORK*NY*10274~PER*IC*PROVIDER SERVICES*TE*8882601010~LE*2120~EB*R*IND*30~REF*18*1U42CY9XP04~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*50*167097830~GE*1*167097830~IEA*1*167097830~