Raw X12 — CIN YZ99149Y

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1956*|*00501*564610547*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1956*610547*X*005010X279A1~ST*270*0547*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*YZ99149Y~EQ*30~DTP*291*D8*20260813~SE*13*0547~GE*1*610547~IEA*1*564610547~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1556*^*00501*530074730*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155646*530074730*X*005010X279A1~ST*271*530074730*005010X279A1~BHT*0022*11*202608121956000001*20260812*155646~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*GOMEZ*LUZ****MI*YZ99149Y~N3*131 TEN EYCK WALK             1C~N4*BROOKLYN*NY*11206~DMG*D8*19480412*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260501~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*PD~MSG*CNTY CD=66 538~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*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*2R91JE5PH14~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*530074730~GE*1*530074730~IEA*1*530074730~