Raw X12 — CIN YZ30656X

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1952*|*00501*564352912*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1952*352912*X*005010X279A1~ST*270*2912*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*YZ30656X~EQ*30~DTP*291*D8*20260813~SE*13*2912~GE*1*352912~IEA*1*564352912~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1552*^*00501*529117930*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155228*529117930*X*005010X279A1~ST*271*529117930*005010X279A1~BHT*0022*11*202608121952000001*20260812*155228~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*BIRMINGHAM*ANITA*L***MI*YZ30656X~N3*366 E 154TH ST                1B~N4*BRONX*NY*10455~DMG*D8*19590607*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20251201~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~EB*R*IND*30~REF*6P*H3387~LS*2120~NM1*P4*2*UNITEDHEALTHCARE DUAL COMPLETE*****PI*H3387~N3*P O BOX 917~N4*NEW YORK*NY*10269~PER*IC*PROVIDER SERVICES*TE*8005144912~LE*2120~EB*R*IND*30~REF*18*2YC4YG7GJ87~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*529117930~GE*1*529117930~IEA*1*529117930~