Raw X12 — CIN NA60132A

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0714*|*00501*518855062*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0714*855062*X*005010X279A1~ST*270*5062*005010X279A1~BHT*0022*13*202608120714000001*20260812*0714~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*202608120714000001*00000000ND~NM1*IL*1******MI*NA60132A~EQ*30~DTP*291*D8*20260812~SE*13*5062~GE*1*855062~IEA*1*518855062~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0314*^*00501*174822630*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031410*174822630*X*005010X279A1~ST*271*174822630*005010X279A1~BHT*0022*11*202608120714000001*20260812*031410~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*202608120714000001*00000000ND~NM1*IL*1*PANKOWSKA*ZOFIA****MI*NA60132A~N3*7800     SHOREFRONT PKWY      9H~N4*FAR ROCKAWAY*NY*11693~DMG*D8*19440314*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=12~LS*2120~NM1*Y2*2*ANTHEM HP LLC MAP*****PI*YO~N3*1 PENN PLZ FL 35~N4*NEW YORK*NY*101193601~PER*IC*PROVIDER SERVICES*TE*2125635570~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*R*IND*30~REF*6P*H8432~LS*2120~NM1*P4*2*EMPIRE MEDIBLUE CORE*****PI*H8432~N3*EMPIRE MEDIBLUE*PO BOX 1407 CHURCH STREET STATION~N4*NEW YORK*NY*100081407~PER*IC*PROVIDER SERVICES*TE*8557311090~LE*2120~EB*R*IND*30~REF*18*5DH2WM2AP86~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*174822630~GE*1*174822630~IEA*1*174822630~