Raw X12 — CIN RV80167N

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260726*1729*|*00501*086955578*1*P*:~GS*HS*00ND*EMEDNYREL*20260726*1729*955578*X*005010X279A1~ST*270*5578*005010X279A1~BHT*0022*13*202607261729000001*20260726*1729~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*202607261729000001*00000000ND~NM1*IL*1******MI*RV80167N~EQ*30~DTP*291*D8*20260726~SE*13*5578~GE*1*955578~IEA*1*086955578~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260726*1329*^*00501*270473530*0*P*|~GS*HB*EMEDNYREL*00ND*20260726*132912*270473530*X*005010X279A1~ST*271*270473530*005010X279A1~BHT*0022*11*202607261729000001*20260726*132912~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*202607261729000001*00000000ND~NM1*IL*1*ANTOINE*MARIA*A***MI*RV80167N~N3*2802     CLARENDON RD         C4~N4*BKLYN*NY*11226~DMG*D8*19380614*F~DTP*472*D8*20260726~DTP*346*D8*20260701~DTP*102*D8*20250801~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~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*6P*H3347~LS*2120~NM1*P4*2*ELDERPLAN*****PI*H3347~N3*ELDERPLAN  INC   745 64TH STREET~N4*BROOKLYN*NY*11220~PER*IC*PROVIDER SERVICES*TE*8003533765~LE*2120~EB*R*IND*30~REF*18*1Q96EP6AT52~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*270473530~GE*1*270473530~IEA*1*270473530~