Raw X12 — CIN SY11022C

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2001*|*00501*564884493*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2001*884493*X*005010X279A1~ST*270*4493*005010X279A1~BHT*0022*13*202608122001000001*20260812*2001~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*202608122001000001*00000000ND~NM1*IL*1******MI*SY11022C~EQ*30~DTP*291*D8*20260813~SE*13*4493~GE*1*884493~IEA*1*564884493~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1601*^*00501*533039130*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160120*533039130*X*005010X279A1~ST*271*533039130*005010X279A1~BHT*0022*11*202608122001000001*20260812*160120~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*202608122001000001*00000000ND~NM1*IL*1*PEREZ*JUTHER*A***MI*SY11022C~N3*422 E 142ND ST~N4*BRONX*NY*10454~DMG*D8*19511030*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260401~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*H3387~LS*2120~NM1*P4*2*UNITEDHEALTHCARE DUAL COMPLETE*****PI*H3387~N3*P O BOX 917~N4*NEW YORK*NY*10269~PER*IC*PROVIDER SERVICES*TE*8005144912~LE*2120~EB*R*IND*30~REF*18*7K62C98CC16~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*41*533039130~GE*1*533039130~IEA*1*533039130~