Raw X12 — CIN UM07028G

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0709*|*00501*518599572*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0709*599572*X*005010X279A1~ST*270*9572*005010X279A1~BHT*0022*13*202608120709000001*20260812*0709~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*202608120709000001*00000000ND~NM1*IL*1******MI*UM07028G~EQ*30~DTP*291*D8*20260812~SE*13*9572~GE*1*599572~IEA*1*518599572~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0309*^*00501*167656730*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*030955*167656730*X*005010X279A1~ST*271*167656730*005010X279A1~BHT*0022*11*202608120709000001*20260812*030955~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*202608120709000001*00000000ND~NM1*IL*1*KANEVSKAYA*GALINA*D***MI*UM07028G~N3*15       CARMEL COURT         B~N4*STATEN ISLAND*NY*10304~DMG*D8*19490401*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260501~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=09~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*8UC3DA9JF93~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*36*167656730~GE*1*167656730~IEA*1*167656730~