Raw X12 — CIN YC16507G

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1957*|*00501*564661259*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1957*661259*X*005010X279A1~ST*270*1259*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*YC16507G~EQ*30~DTP*291*D8*20260813~SE*13*1259~GE*1*661259~IEA*1*564661259~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1557*^*00501*530264630*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155736*530264630*X*005010X279A1~ST*271*530264630*005010X279A1~BHT*0022*11*202608121957000001*20260812*155736~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*HEDGEPETH*DEBORAH*A***MI*YC16507G~N3*127 W 43RD ST RM 812~N4*NEW YORK*NY*10036~DMG*D8*19530914*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260501~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=66 565~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*H3359~LS*2120~NM1*P4*2*HEALTHFIRST MEDICARE PLAN*****PI*H3359~N3*HEALTHFIRST MEDICARE PLAN  PO BOX 5165~N4*NEW YORK*NY*10274~PER*IC*PROVIDER SERVICES*TE*8882601010~LE*2120~EB*R*IND*30~REF*18*6K79XJ8YX44~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*530264630~GE*1*530264630~IEA*1*530264630~