Raw X12 — CIN TK96993X

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1956*|*00501*564570142*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1956*570142*X*005010X279A1~ST*270*0142*005010X279A1~BHT*0022*13*202608121956000001*20260812*1956~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*202608121956000001*00000000ND~NM1*IL*1******MI*TK96993X~EQ*30~DTP*291*D8*20260813~SE*13*0142~GE*1*570142~IEA*1*564570142~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1556*^*00501*529924630*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155605*529924630*X*005010X279A1~ST*271*529924630*005010X279A1~BHT*0022*11*202608121956000001*20260812*155605~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*202608121956000001*00000000ND~NM1*IL*1*FRANCIS*OLGA****MI*TK96993X~N3*1590     MADISON AVENUE       10202~N4*NEW YORK*NY*10029~DMG*D8*19770320*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20251001~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~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*W*IND*CQ~LS*2120~NM1*Y2*2*TREMONT HELPS INC*****XX*1205460581~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*SRH CHN LEAD HEALTH HOME LLC*****XX*1750053948~LE*2120~EB*R*IND*30~REF*6P*H3533~LS*2120~NM1*P4*2*HUMANA HEALTH COMPANY OF NY*****PI*H3533~N3*100 ELWOOD DAVIS ROAD~N4*NORTH SYRACUSE*NY*13212~PER*IC*PROVIDER SERVICES*TE*8005738597~LE*2120~EB*R*IND*30~REF*18*2JD0AH2MJ90~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*52*529924630~GE*1*529924630~IEA*1*529924630~