Raw X12 — CIN ZG32011S

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1911*|*00501*648311568*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1911*311568*X*005010X279A1~ST*270*1568*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*ZG32011S~EQ*30~DTP*291*D8*20260814~SE*13*1568~GE*1*311568~IEA*1*648311568~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1511*^*00501*536279430*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151147*536279430*X*005010X279A1~ST*271*536279430*005010X279A1~BHT*0022*11*202608131911000001*20260813*151147~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*PEREZ*IVETTE****MI*ZG32011S~N3*374 E 155TH ST                1D~N4*BRONX*NY*10455~DMG*D8*19560911*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~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*W*IND*CQ~LS*2120~NM1*Y2*2*UNIVERSITY BEHAVIORAL ASSOCIATES IN*****XX*1760756852~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*MONTEFIORE MEDICAL CENTER*****XX*1831461847~LE*2120~EB*R*IND*30~REF*6P*H3312~LS*2120~NM1*P4*2*AETNA MEDICARE*****PI*H3312~N3*151 FARMINGTON AVENUE~N4*HARTFORD*CT*06156~PER*IC*PROVIDER SERVICES*TE*8002825366~LE*2120~EB*R*IND*30~REF*18*2JJ7VC7MH52~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*52*536279430~GE*1*536279430~IEA*1*536279430~