Raw X12 — CIN XD46315Q

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0710*|*00501*518613564*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0710*613564*X*005010X279A1~ST*270*3564*005010X279A1~BHT*0022*13*202608120710000001*20260812*0710~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*202608120710000001*00000000ND~NM1*IL*1******MI*XD46315Q~EQ*30~DTP*291*D8*20260812~SE*13*3564~GE*1*613564~IEA*1*518613564~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0310*^*00501*167770230*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031009*167770230*X*005010X279A1~ST*271*167770230*005010X279A1~BHT*0022*11*202608120710000001*20260812*031009~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*202608120710000001*00000000ND~NM1*IL*1*KATS*MARK****MI*XD46315Q~N3*2533     BATCHELDER STREET    4 O~N4*BROOKLYN*NY*11235~DMG*D8*19390905*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=06~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*1HH4CD7WT99~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*37*167770230~GE*1*167770230~IEA*1*167770230~