Raw X12 — CIN RR04362T

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0705*|*00501*518341293*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0705*341293*X*005010X279A1~ST*270*1293*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*RR04362T~EQ*30~DTP*291*D8*20260812~SE*13*1293~GE*1*341293~IEA*1*518341293~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0305*^*00501*167416430*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030536*167416430*X*005010X279A1~ST*271*167416430*005010X279A1~BHT*0022*11*202608120705000001*20260812*030536~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*BELLE*LILIA****MI*RR04362T~N3*1755     E 13TH ST            D7~N4*BROOKLYN*NY*11229~DMG*D8*19591227*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=66 5H9~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*6P*H3312~LS*2120~NM1*P4*2*AETNA MEDICARE*****PI*H3312~N3*151 FARMINGTON AVENUE~N4*HARTFORD*CT*06156~PER*IC*PROVIDER SERVICES*TE*8002825366~LE*2120~EB*R*IND*30~REF*18*6X13DJ5CX90~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*167416430~GE*1*167416430~IEA*1*167416430~