Raw X12 — CIN ZE12757J

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1951*|*00501*564273941*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1951*273941*X*005010X279A1~ST*270*3941*005010X279A1~BHT*0022*13*202608121951000001*20260812*1951~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*202608121951000001*00000000ND~NM1*IL*1******MI*ZE12757J~EQ*30~DTP*291*D8*20260813~SE*13*3941~GE*1*273941~IEA*1*564273941~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1551*^*00501*528717430*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155110*528717430*X*005010X279A1~ST*271*528717430*005010X279A1~BHT*0022*11*202608121951000001*20260812*155110~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*202608121951000001*00000000ND~NM1*IL*1*ABRAMS*KEVIN****MI*ZE12757J~N3*700      E 156TH ST           4H~N4*BRONX*NY*10455~DMG*D8*19810425*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 040~MSG*RECERT MONTH=12~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~SE*31*528717430~GE*1*528717430~IEA*1*528717430~