Raw X12 — CIN ZU80503U

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1951*|*00501*564278832*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1951*278832*X*005010X279A1~ST*270*8832*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*ZU80503U~EQ*30~DTP*291*D8*20260813~SE*13*8832~GE*1*278832~IEA*1*564278832~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1551*^*00501*528734330*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155114*528734330*X*005010X279A1~ST*271*528734330*005010X279A1~BHT*0022*11*202608121951000001*20260812*155114~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*ACEVEDO*MARIA*J***MI*ZU80503U~N3*1239 STANLEY AVENUE           2G~N4*BROOKLYN*NY*11208~DMG*D8*19611207*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~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~SE*29*528734330~GE*1*528734330~IEA*1*528734330~