Raw X12 — CIN WB83907D

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0706*|*00501*518376615*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0706*376615*X*005010X279A1~ST*270*6615*005010X279A1~BHT*0022*13*202608120706000001*20260812*0706~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*202608120706000001*00000000ND~NM1*IL*1******MI*WB83907D~EQ*30~DTP*291*D8*20260812~SE*13*6615~GE*1*376615~IEA*1*518376615~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0306*^*00501*167450230*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030612*167450230*X*005010X279A1~ST*271*167450230*005010X279A1~BHT*0022*11*202608120706000001*20260812*030612~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*202608120706000001*00000000ND~NM1*IL*1*BRWINOWSKI*MARIA*K***MI*WB83907D~N3*10143    95TH STREET~N4*QUEENS*NY*11416~DMG*D8*19471011*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=02~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*H5599~LS*2120~NM1*P4*2*WELLCARE FIDELIS DUAL ACCESS*****PI*H5599~N3*25-01 JACKSON AVE~N4*LONG ISLAND CITY*NY*11101~PER*IC*PROVIDER SERVICES*TE*8883433547~LE*2120~EB*R*IND*30~REF*18*1M71V31JK94~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*167450230~GE*1*167450230~IEA*1*167450230~