Raw X12 — CIN XG92129F

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1957*|*00501*564658548*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1957*658548*X*005010X279A1~ST*270*8548*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*XG92129F~EQ*30~DTP*291*D8*20260813~SE*13*8548~GE*1*658548~IEA*1*564658548~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1557*^*00501*530255230*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155734*530255230*X*005010X279A1~ST*271*530255230*005010X279A1~BHT*0022*11*202608121957000001*20260812*155734~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*HARRIS*CHARLES****MI*XG92129F~N3*330      W 95TH ST            321~N4*NEW YORK*NY*10025~DMG*D8*19580202*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CF~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=01~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*W*IND*CQ~LS*2120~NM1*Y2*2*HOUSING WORKS INC AI*****XX*1538379573~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*COMMUNITY CARE MANAGEMENT PARTNERS*****XX*1366780850~LE*2120~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*4N85T84AC78~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*53*530255230~GE*1*530255230~IEA*1*530255230~