Raw X12 — CIN WW60302M

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1957*|*00501*564640228*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1957*640228*X*005010X279A1~ST*270*0228*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*WW60302M~EQ*30~DTP*291*D8*20260813~SE*13*0228~GE*1*640228~IEA*1*564640228~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1557*^*00501*530182330*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155715*530182330*X*005010X279A1~ST*271*530182330*005010X279A1~BHT*0022*11*202608121957000001*20260812*155715~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*GRIER*LANCE****MI*WW60302M~N3*755      E 165TH ST           2G~N4*BRONX*NY*10456~DMG*D8*19670730*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260201~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=12~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*18*095569253~LS*2120~NM1*P4*2*HIP GNY MEDICARE COST*****PI*DR~N3*7 WEST 34TH ST~N4*NEW YORK*NY*10001~PER*IC*PROVIDER SERVICES*TE*8004478255~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*7DG8PA0XP55~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*50*530182330~GE*1*530182330~IEA*1*530182330~