Raw X12 — CIN VW85280X

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*0720*|*00501*519214305*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*0720*214305*X*005010X279A1~ST*270*4305*005010X279A1~BHT*0022*13*202608120720000001*20260812*0720~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*202608120720000001*00000000ND~NM1*IL*1******MI*VW85280X~EQ*30~DTP*291*D8*20260812~SE*13*4305~GE*1*214305~IEA*1*519214305~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*0320*^*00501*176570730*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*032009*176570730*X*005010X279A1~ST*271*176570730*005010X279A1~BHT*0022*11*202608120720000001*20260812*032009~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*202608120720000001*00000000ND~NM1*IL*1*SHUSTERMAN*TSILA****MI*VW85280X~N3*25       BAY 31 STREET        3~N4*BROOKLYN*NY*11214~DMG*D8*19520819*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*PD~MSG*S1~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*W*IND*CQ~LS*2120~NM1*Y2*2*JEMCARE LLC*****XX*1265926216~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*COMMUNITY CARE MANAGEMENT PARTNERS*****XX*1366780850~LE*2120~EB*R*IND*30~REF*18*2H52UE4EC95~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*46*176570730~GE*1*176570730~IEA*1*176570730~