Raw X12 — CIN QY97867A

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2000*|*00501*564826705*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2000*826705*X*005010X279A1~ST*270*6705*005010X279A1~BHT*0022*13*202608122000000001*20260812*2000~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*202608122000000001*00000000ND~NM1*IL*1******MI*QY97867A~EQ*30~DTP*291*D8*20260813~SE*13*6705~GE*1*826705~IEA*1*564826705~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1600*^*00501*531094630*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160022*531094630*X*005010X279A1~ST*271*531094630*005010X279A1~BHT*0022*11*202608122000000001*20260812*160022~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*202608122000000001*00000000ND~NM1*IL*1*MORENO*HUMBERTO****MI*QY97867A~N3*25-51 86 STREET               1~N4*EAST ELMHURST*NY*11369~DMG*D8*19470611*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260801~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=04~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*7W15YT1JV75~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*531094630~GE*1*531094630~IEA*1*531094630~