Raw X12 — CIN XF31436C

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2000*|*00501*564836445*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2000*836445*X*005010X279A1~ST*270*6445*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*XF31436C~EQ*30~DTP*291*D8*20260813~SE*13*6445~GE*1*836445~IEA*1*564836445~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1600*^*00501*531338530*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160032*531338530*X*005010X279A1~ST*271*531338530*005010X279A1~BHT*0022*11*202608122000000001*20260812*160032~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*NOEL*OLIVE****MI*XF31436C~N3*1200 PARK PLACE~N4*BROOKLYN*NY*11213~DMG*D8*19461026*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20251201~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*S1~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*H5522~LS*2120~NM1*P4*2*AETNA MEDICARE*****PI*H5522~N3*PO BOX 7405~N4*LONDON*KY*40742~PER*IC*PROVIDER SERVICES*TE*8887594415~LE*2120~EB*R*IND*30~REF*18*W247403900~REF*6P*011533001200800~LS*2120~NM1*P4*2*AETNA (DENTAL)*****PI*ACD~N3*PO BOX 14094~N4*LEXINGTON*KY*405124094~PER*IC*PROVIDER SERVICES*TE*8772386200~LE*2120~EB*R*IND*30~REF*18*7G76PU0NG71~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*53*531338530~GE*1*531338530~IEA*1*531338530~