Raw X12 — CIN SN50598Q

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0707*|*00501*518450642*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0707*450642*X*005010X279A1~ST*270*0642*005010X279A1~BHT*0022*13*202608120707000001*20260812*0707~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*202608120707000001*00000000ND~NM1*IL*1******MI*SN50598Q~EQ*30~DTP*291*D8*20260812~SE*13*0642~GE*1*450642~IEA*1*518450642~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0307*^*00501*167519730*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030726*167519730*X*005010X279A1~ST*271*167519730*005010X279A1~BHT*0022*11*202608120707000001*20260812*030726~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*202608120707000001*00000000ND~NM1*IL*1*EJTMINOWICZ*MAREK****MI*SN50598Q~N3*7901     BAY PKWY             3F~N4*BROOKLYN*NY*11214~DMG*D8*19550914*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260201~EB*U*IND*30**ELIGIBLE PCP~MSG*S1~MSG*CNTY CD=66 548~MSG*RECERT MONTH=08~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*7X89MQ1ME49~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*167519730~GE*1*167519730~IEA*1*167519730~