Raw X12 — CIN TB55552Q

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2002*|*00501*564931549*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2002*931549*X*005010X279A1~ST*270*1549*005010X279A1~BHT*0022*13*202608122002000001*20260812*2002~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*202608122002000001*00000000ND~NM1*IL*1******MI*TB55552Q~EQ*30~DTP*291*D8*20260813~SE*13*1549~GE*1*931549~IEA*1*564931549~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1602*^*00501*533211830*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160207*533211830*X*005010X279A1~ST*271*533211830*005010X279A1~BHT*0022*11*202608122002000001*20260812*160207~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*202608122002000001*00000000ND~NM1*IL*1*REMY*MARIE****MI*TB55552Q~N3*140 SAINT EDWARDS STREET~N4*BROOKLYN*NY*11201~DMG*D8*19800712*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20251201~EB*U*IND*30**ELIGIBLE PCP~MSG*N6~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=06~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*18*9211802LE2020~REF*6P*8312~LS*2120~NM1*P4*2*CAREMARK (CVS)*****PI*DV~N3*POST OFFICE BOX 52057~N4*PHOENIX*AZ*850722057~PER*IC*PROVIDER SERVICES*TE*8006245060~LE*2120~SE*40*533211830~GE*1*533211830~IEA*1*533211830~