Raw X12 — CIN PH58537Z

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0716*|*00501*518992003*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0716*992003*X*005010X279A1~ST*270*2003*005010X279A1~BHT*0022*13*202608120716000001*20260812*0716~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*202608120716000001*00000000ND~NM1*IL*1******MI*PH58537Z~EQ*30~DTP*291*D8*20260812~SE*13*2003~GE*1*992003~IEA*1*518992003~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0316*^*00501*176280930*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*031627*176280930*X*005010X279A1~ST*271*176280930*005010X279A1~BHT*0022*11*202608120716000001*20260812*031627~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*202608120716000001*00000000ND~NM1*IL*1*SEVERINOVSKY*INA****MI*PH58537Z~N3*3601 SURF AVE                 16C~N4*BROOKLYN*NY*11224~DMG*D8*19350908*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260401~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 5H9~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*2WY3FP4EU02~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*35*176280930~GE*1*176280930~IEA*1*176280930~