Raw X12 — CIN TM63598H

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1957*|*00501*564630504*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1957*630504*X*005010X279A1~ST*270*0504*005010X279A1~BHT*0022*13*202608121957000001*20260812*1957~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*202608121957000001*00000000ND~NM1*IL*1******MI*TM63598H~EQ*30~DTP*291*D8*20260813~SE*13*0504~GE*1*630504~IEA*1*564630504~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1557*^*00501*530149730*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155706*530149730*X*005010X279A1~ST*271*530149730*005010X279A1~BHT*0022*11*202608121957000001*20260812*155706~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*202608121957000001*00000000ND~NM1*IL*1*GOTAY*ANGELA****MI*TM63598H~N3*2270     NEWBOLD AVE          2~N4*BRONX*NY*10462~DMG*D8*19620531*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20251101~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=05~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*METRO CARE MANAGEMENT LLC*****XX*1922565118~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*COORDINATED BEHAVIORAL CARE INC*****XX*1730451071~LE*2120~EB*R*IND*30~REF*6P*H6988~LS*2120~NM1*P4*2*ANTHEM MEDICARE ADVANTAGE*****PI*H6988~N3*PO BOX 1407 CHURCH STREET STATION~N4*NEW YORK*NY*100081407~PER*IC*PROVIDER SERVICES*TE*8006641504~LE*2120~EB*R*IND*30~REF*18*9XJ5AM9XQ88~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*51*530149730~GE*1*530149730~IEA*1*530149730~