Raw X12 — CIN KD57352G

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1911*|*00501*648307565*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1911*307565*X*005010X279A1~ST*270*7565*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*KD57352G~EQ*30~DTP*291*D8*20260814~SE*13*7565~GE*1*307565~IEA*1*648307565~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1511*^*00501*536264430*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151143*536264430*X*005010X279A1~ST*271*536264430*005010X279A1~BHT*0022*11*202608131911000001*20260813*151143~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*PENARIJODEENCA*ELENA****MI*KD57352G~N3*64        SCHOLES ST          7D~N4*BROOKLYN*NY*11206~DMG*D8*19590215*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*CNTY CD=66 066~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~EB*W*IND*CQ~LS*2120~NM1*Y2*2*NYU LANGONE HOSPITALS*****XX*1619341716~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*SOUTHWEST BROOKLYN HEALTH HOME LLC*****XX*1023354933~LE*2120~EB*R*IND*30~REF*6P*H5549~LS*2120~NM1*P4*2*VNS CHOICE MEDICARE*****PI*H5549~N3*1250 BROADWAY  3RD FLOOR~N4*NEW YORK*NY*10001~PER*IC*PROVIDER SERVICES*TE*8665976674~LE*2120~EB*R*IND*30~REF*18*2E00U98CN09~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*52*536264430~GE*1*536264430~IEA*1*536264430~