Raw X12 — CIN ZU28387N

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2000*|*00501*564845452*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2000*845452*X*005010X279A1~ST*270*5452*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*ZU28387N~EQ*30~DTP*291*D8*20260813~SE*13*5452~GE*1*845452~IEA*1*564845452~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1600*^*00501*531474130*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160041*531474130*X*005010X279A1~ST*271*531474130*005010X279A1~BHT*0022*11*202608122000000001*20260812*160041~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*ORTEGA*MARIA****MI*ZU28387N~N3*303 VERNON AVE                2C~N4*BKLYN*NY*11206~DMG*D8*19550507*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~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*H0423~LS*2120~NM1*P4*2*METROPLUS HEALTH PLAN, INC.*****PI*H0423~N3*160 WATER STREET~N4*NEW YORK*NY*10038~PER*IC*PROVIDER SERVICES*TE*8669860356~LE*2120~EB*R*IND*30~REF*18*5RY1HP2VP99~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*41*531474130~GE*1*531474130~IEA*1*531474130~