Raw X12 — CIN ZN91763R

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1951*|*00501*564279835*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1951*279835*X*005010X279A1~ST*270*9835*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*ZN91763R~EQ*30~DTP*291*D8*20260813~SE*13*9835~GE*1*279835~IEA*1*564279835~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1551*^*00501*528738630*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155115*528738630*X*005010X279A1~ST*271*528738630*005010X279A1~BHT*0022*11*202608121951000001*20260812*155115~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*GEORGINA****MI*ZN91763R~N3*264 S 1ST  ST                 1D~N4*BROOKLYN*NY*11211~DMG*D8*19410509*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260801~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*114663003~REF*6P*HFPP01~LS*2120~NM1*P4*2*DAVIS VISION*****PI*90~N3*PO BOX 1501~N4*LATHAM*NY*121108001~PER*IC*PROVIDER SERVICES*TE*8009995431~LE*2120~EB*R*IND*30~REF*6P*H5599~LS*2120~NM1*P4*2*WELLCARE FIDELIS DUAL ACCESS*****PI*H5599~N3*25-01 JACKSON AVE~N4*LONG ISLAND CITY*NY*11101~PER*IC*PROVIDER SERVICES*TE*8883433547~LE*2120~EB*R*IND*30~REF*18*1J64UW2MM93~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*52*528738630~GE*1*528738630~IEA*1*528738630~