Raw X12 — CIN ZF51333V

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1955*|*00501*564512080*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1955*512080*X*005010X279A1~ST*270*2080*005010X279A1~BHT*0022*13*202608121955000001*20260812*1955~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*202608121955000001*00000000ND~NM1*IL*1******MI*ZF51333V~EQ*30~DTP*291*D8*20260813~SE*13*2080~GE*1*512080~IEA*1*564512080~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1555*^*00501*529706630*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155507*529706630*X*005010X279A1~ST*271*529706630*005010X279A1~BHT*0022*11*202608121955000001*20260812*155507~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*202608121955000001*00000000ND~NM1*IL*1*DELOSSANTOS*JUANA****MI*ZF51333V~N3*86-23    107 ST~N4*RICHMOND HILL*NY*11418~DMG*D8*19390107*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260301~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=09~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*2HG2M63TQ96~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*35*529706630~GE*1*529706630~IEA*1*529706630~