Raw X12 — CIN YB28804N

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1952*|*00501*564351913*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1952*351913*X*005010X279A1~ST*270*1913*005010X279A1~BHT*0022*13*202608121952000001*20260812*1952~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*202608121952000001*00000000ND~NM1*IL*1******MI*YB28804N~EQ*30~DTP*291*D8*20260813~SE*13*1913~GE*1*351913~IEA*1*564351913~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1552*^*00501*529115230*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155227*529115230*X*005010X279A1~ST*271*529115230*005010X279A1~BHT*0022*11*202608121952000001*20260812*155227~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*202608121952000001*00000000ND~NM1*IL*1*BETHEA*CHRISTINE****MI*YB28804N~N3*361      LIVONIA AVENUE       11G~N4*BROOKLYN*NY*11212~DMG*D8*19581220*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260501~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=01~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*6P*H3359~LS*2120~NM1*P4*2*HEALTHFIRST MEDICARE PLAN*****PI*H3359~N3*HEALTHFIRST MEDICARE PLAN  PO BOX 5165~N4*NEW YORK*NY*10274~PER*IC*PROVIDER SERVICES*TE*8882601010~LE*2120~EB*R*IND*30~REF*18*7K00FK0DY28~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*44*529115230~GE*1*529115230~IEA*1*529115230~