Raw X12 — CIN VT25777K

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1910*|*00501*648254877*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1910*254877*X*005010X279A1~ST*270*4877*005010X279A1~BHT*0022*13*202608131910000001*20260813*1910~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*202608131910000001*00000000ND~NM1*IL*1******MI*VT25777K~EQ*30~DTP*291*D8*20260814~SE*13*4877~GE*1*254877~IEA*1*648254877~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1510*^*00501*535741730*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151050*535741730*X*005010X279A1~ST*271*535741730*005010X279A1~BHT*0022*11*202608131910000001*20260813*151050~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*202608131910000001*00000000ND~NM1*IL*1*FERNANDEZ*JUSTIN****MI*VT25777K~N3*340 S 3RD ST                  E1~N4*BROOKLYN*NY*11211~DMG*D8*19930822*M~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*CO~MSG*PD~MSG*95~MSG*CNTY CD=66 500~LS*2120~NM1*Y2*2*ANTHEM HP LLC MAINSTREAM*****PI*KP~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*1*IND*88~SE*31*535741730~GE*1*535741730~IEA*1*535741730~