Raw X12 — CIN ZB45520G

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1956*|*00501*564601194*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1956*601194*X*005010X279A1~ST*270*1194*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*ZB45520G~EQ*30~DTP*291*D8*20260813~SE*13*1194~GE*1*601194~IEA*1*564601194~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1556*^*00501*530042630*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155636*530042630*X*005010X279A1~ST*271*530042630*005010X279A1~BHT*0022*11*202608121956000001*20260812*155636~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*GILLIAM*TIFFANY****MI*ZB45520G~N3*755 GATES AVE                 2E~N4*BROOKLYN*NY*11221~DMG*D8*19810518*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~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*W*IND*CQ~LS*2120~NM1*Y2*2*INTERBOROUGH DEV/CONSULT CTRS*****XX*1588611842~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*COORDINATED BEHAVIORAL CARE INC*****XX*1730451071~LE*2120~SE*40*530042630~GE*1*530042630~IEA*1*530042630~