Raw X12 — CIN ZX82213X

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1957*|*00501*564653246*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1957*653246*X*005010X279A1~ST*270*3246*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*ZX82213X~EQ*30~DTP*291*D8*20260813~SE*13*3246~GE*1*653246~IEA*1*564653246~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1557*^*00501*530232230*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155728*530232230*X*005010X279A1~ST*271*530232230*005010X279A1~BHT*0022*11*202608121957000001*20260812*155728~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*GUZMAN*LUZ*G***MI*ZX82213X~N3*15218 UNION TURNPIKE          5T~N4*FLUSHING*NY*11367~DMG*D8*19530705*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~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*R*IND*30~REF*6P*H3387~LS*2120~NM1*P4*2*UNITEDHEALTHCARE DUAL COMPLETE*****PI*H3387~N3*P O BOX 917~N4*NEW YORK*NY*10269~PER*IC*PROVIDER SERVICES*TE*8005144912~LE*2120~EB*R*IND*30~REF*18*5K78Q28PA36~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*530232230~GE*1*530232230~IEA*1*530232230~