Raw X12 — CIN YX34046Y

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1955*|*00501*564529092*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1955*529092*X*005010X279A1~ST*270*9092*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*YX34046Y~EQ*30~DTP*291*D8*20260813~SE*13*9092~GE*1*529092~IEA*1*564529092~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1555*^*00501*529771630*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155524*529771630*X*005010X279A1~ST*271*529771630*005010X279A1~BHT*0022*11*202608121955000001*20260812*155524~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*EADDY*MICHAEL****MI*YX34046Y~N3*109      LEWIS AVENUE         1K~N4*BROOKLYN*NY*11206~DMG*D8*19560915*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260801~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*PD~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=03~LS*2120~NM1*Y2*2*ANTHEM HP LLC MAP*****PI*YO~N3*1 PENN PLZ FL 35~N4*NEW YORK*NY*101193601~PER*IC*PROVIDER SERVICES*TE*2125635570~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*W*IND*CQ~LS*2120~NM1*Y2*2*PUERTO RICAN FAMILY INST MH*****XX*1588873327~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*SOUTHWEST BROOKLYN HEALTH HOME LLC*****XX*1023354933~LE*2120~EB*R*IND*30~REF*6P*H8432~LS*2120~NM1*P4*2*EMPIRE MEDIBLUE CORE*****PI*H8432~N3*EMPIRE MEDIBLUE*PO BOX 1407 CHURCH STREET STATION~N4*NEW YORK*NY*100081407~PER*IC*PROVIDER SERVICES*TE*8557311090~LE*2120~EB*R*IND*30~REF*18*7EN1UH4VU04~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*53*529771630~GE*1*529771630~IEA*1*529771630~