Raw X12 — CIN UH91058U

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1911*|*00501*648297761*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1911*297761*X*005010X279A1~ST*270*7761*005010X279A1~BHT*0022*13*202608131911000001*20260813*1911~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*202608131911000001*00000000ND~NM1*IL*1******MI*UH91058U~EQ*30~DTP*291*D8*20260814~SE*13*7761~GE*1*297761~IEA*1*648297761~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1511*^*00501*536227830*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151133*536227830*X*005010X279A1~ST*271*536227830*005010X279A1~BHT*0022*11*202608131911000001*20260813*151133~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*202608131911000001*00000000ND~NM1*IL*1*MOSTOVAYA*YELIZAVETA****MI*UH91058U~N3*0-79 27TH ST~N4*FAIR LAWN*NJ*07410~DMG*D8*19380301*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20251201~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~MSG*CNTY CD=66 5H9~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*2E06HT0KV45~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*34*536227830~GE*1*536227830~IEA*1*536227830~