Raw X12 — CIN XY19836K

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2002*|*00501*564947567*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2002*947567*X*005010X279A1~ST*270*7567*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*XY19836K~EQ*30~DTP*291*D8*20260813~SE*13*7567~GE*1*947567~IEA*1*564947567~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1602*^*00501*533280030*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160223*533280030*X*005010X279A1~ST*271*533280030*005010X279A1~BHT*0022*11*202608122002000001*20260812*160223~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*RIVERA*LUIS*A***MI*XY19836K~N3*138-42   90 AVENUE            D9~N4*JAMAICA*NY*11435~DMG*D8*19540608*M~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=03~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*ETRBJ4753815~REF*6P*720905DM3A~LS*2120~NM1*P4*2*ANTHEM BC/BS (EMPIRE)*****PI*12~N3*PO BOX 1407 CHURCH ST STATION*ATTN  CLAIMS DEPT~N4*NEW YORK*NY*100081407~PER*IC*PROVIDER SERVICES*TE*8005235978~LE*2120~EB*R*IND*30~REF*18*00475381500~REF*6P*32BJRX~LS*2120~NM1*P4*2*OPTUM RX*****PI*ORX~N3*PO BOX 8082~N4*WAUSAU*WI*544028082~PER*IC*PROVIDER SERVICES*TE*8002071561~LE*2120~SE*48*533280030~GE*1*533280030~IEA*1*533280030~