Raw X12 — CIN KZ91213Z

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2002*|*00501*564971104*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2002*971104*X*005010X279A1~ST*270*1104*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*KZ91213Z~EQ*30~DTP*291*D8*20260813~SE*13*1104~GE*1*971104~IEA*1*564971104~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1602*^*00501*533379430*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160246*533379430*X*005010X279A1~ST*271*533379430*005010X279A1~BHT*0022*11*202608122002000001*20260812*160246~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*RODRIGUEZ*IVONNE****MI*KZ91213Z~N3*365      E 183RD ST APT 7DR   7DR~N4*BRONX*NY*10458~DMG*D8*19640914*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20251001~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 044~MSG*RECERT MONTH=12~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~SE*29*533379430~GE*1*533379430~IEA*1*533379430~