Raw X12 — CIN NS54933A

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1955*|*00501*564520456*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1955*520456*X*005010X279A1~ST*270*0456*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*NS54933A~EQ*30~DTP*291*D8*20260813~SE*13*0456~GE*1*520456~IEA*1*564520456~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1555*^*00501*529741430*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155516*529741430*X*005010X279A1~ST*271*529741430*005010X279A1~BHT*0022*11*202608121955000001*20260812*155516~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*DORE*CHARLES*A***MI*NS54933A~N3*1770     BRUCKNER BLVD        4G~N4*BRONX*NY*10473~DMG*D8*19400203*M~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=02~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*W24724887801~REF*6P*011533001200800~LS*2120~NM1*P4*2*AETNA (DENTAL)*****PI*ACD~N3*PO BOX 14094~N4*LEXINGTON*KY*405124094~PER*IC*PROVIDER SERVICES*TE*8772386200~LE*2120~EB*R*IND*30~REF*6P*H5522~LS*2120~NM1*P4*2*AETNA MEDICARE*****PI*H5522~N3*PO BOX 7405~N4*LONDON*KY*40742~PER*IC*PROVIDER SERVICES*TE*8887594415~LE*2120~EB*R*IND*30~REF*18*2YR4TD5YY61~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*53*529741430~GE*1*529741430~IEA*1*529741430~