Raw X12 — CIN SB37395G

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0711*|*00501*518666949*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0711*666949*X*005010X279A1~ST*270*6949*005010X279A1~BHT*0022*13*202608120711000001*20260812*0711~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*202608120711000001*00000000ND~NM1*IL*1******MI*SB37395G~EQ*30~DTP*291*D8*20260812~SE*13*6949~GE*1*666949~IEA*1*518666949~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0311*^*00501*169140230*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031102*169140230*X*005010X279A1~ST*271*169140230*005010X279A1~BHT*0022*11*202608120711000001*20260812*031102~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*202608120711000001*00000000ND~NM1*IL*1*KOTARBA*MARIA****MI*SB37395G~N3*3 CLIFFORD PLACE              1~N4*BROOKLYN*NY*11222~DMG*D8*19450909*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260101~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*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*1UP6QF3HC71~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*169140230~GE*1*169140230~IEA*1*169140230~