Raw X12 — CIN NF44286P

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0710*|*00501*518628589*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0710*628589*X*005010X279A1~ST*270*8589*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*NF44286P~EQ*30~DTP*291*D8*20260812~SE*13*8589~GE*1*628589~IEA*1*518628589~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0310*^*00501*168189230*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031024*168189230*X*005010X279A1~ST*271*168189230*005010X279A1~BHT*0022*11*202608120710000001*20260812*031024~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*KHODORKOVSKY*TSILYA****MI*NF44286P~N3*1475     GENEVA LOOP          7C~N4*BROOKLYN*NY*11239~DMG*D8*19461122*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=04~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*YLA931083973~REF*6P*157157~LS*2120~NM1*P4*2*ANTHEM BC/BS (EMPIRE)*****PI*12~N3*PO BOX 1407 CHURCH ST STATION*ATTN  CLAIMS DEPT~N4*NEW YORK*NY*100081407~PER*IC*PROVIDER SERVICES*TE*8005235978~LE*2120~EB*R*IND*30~REF*18*5AR1EE2AP03~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*44*168189230~GE*1*168189230~IEA*1*168189230~