Raw X12 — CIN XA69778J

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260812*2007*|*00501*565220301*1*P*:~GS*HS*00ND*EMEDNYREL*20260812*2007*220301*X*005010X279A1~ST*270*0301*005010X279A1~BHT*0022*13*202608122007000001*20260812*2007~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*202608122007000001*00000000ND~NM1*IL*1******MI*XA69778J~EQ*30~DTP*291*D8*20260813~SE*13*0301~GE*1*220301~IEA*1*565220301~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260812*1606*^*00501*534276330*0*P*|~GS*HB*EMEDNYREL*00ND*20260812*160655*534276330*X*005010X279A1~ST*271*534276330*005010X279A1~BHT*0022*11*202608122007000001*20260812*160655~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*202608122007000001*00000000ND~NM1*IL*1*SANGANOO*MARGARET*N***MI*XA69778J~N3*3668 OLINVILLE AVE~N4*BRONX*NY*10467~DMG*D8*19490720*F~DTP*472*D8*20260812~DTP*346*D8*20260801~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=12~LS*2120~NM1*Y2*2*ANTHEM HP LLC MAP*****PI*YO~N3*1 PENN PLZ FL 35~N4*NEW YORK*NY*101193601~PER*IC*PROVIDER SERVICES*TE*2125635570~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*R*IND*30~REF*6P*H6988~LS*2120~NM1*P4*2*ANTHEM MEDICARE ADVANTAGE*****PI*H6988~N3*PO BOX 1407 CHURCH STREET STATION~N4*NEW YORK*NY*100081407~PER*IC*PROVIDER SERVICES*TE*8006641504~LE*2120~EB*R*IND*30~REF*18*9RF0H89YK21~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*43*534276330~GE*1*534276330~IEA*1*534276330~