Raw X12 — CIN KJ35087R

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*1958*|*00501*564696632*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*1958*696632*X*005010X279A1~ST*270*6632*005010X279A1~BHT*0022*13*202608121958000001*20260812*1958~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*202608121958000001*00000000ND~NM1*IL*1******MI*KJ35087R~EQ*30~DTP*291*D8*20260813~SE*13*6632~GE*1*696632~IEA*1*564696632~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1558*^*00501*530401930*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*155812*530401930*X*005010X279A1~ST*271*530401930*005010X279A1~BHT*0022*11*202608121958000001*20260812*155812~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*202608121958000001*00000000ND~NM1*IL*1*JHANGOWA*TSAMCHOE****MI*KJ35087R~N3*4155     CASE STREET          C3~N4*ELMHURST*NY*11373~DMG*D8*19781101*F~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=11~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~SE*29*530401930~GE*1*530401930~IEA*1*530401930~