Raw X12 — CIN ZN75519S

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1957*|*00501*564646462*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1957*646462*X*005010X279A1~ST*270*6462*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*ZN75519S~EQ*30~DTP*291*D8*20260813~SE*13*6462~GE*1*646462~IEA*1*564646462~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1557*^*00501*530205130*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155722*530205130*X*005010X279A1~ST*271*530205130*005010X279A1~BHT*0022*11*202608121957000001*20260812*155722~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*GUEST*JASON****MI*ZN75519S~N3*111      SUNKEN GARDEN LOOP~N4*NEW YORK*NY*10035~DMG*D8*19811003*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 023~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*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*7GR6XH8AY71~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*40*530205130~GE*1*530205130~IEA*1*530205130~