Raw X12 — CIN UR67059E

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1912*|*00501*648321597*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1912*321597*X*005010X279A1~ST*270*1597*005010X279A1~BHT*0022*13*202608131912000001*20260813*1912~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*202608131912000001*00000000ND~NM1*IL*1******MI*UR67059E~EQ*30~DTP*291*D8*20260814~SE*13*1597~GE*1*321597~IEA*1*648321597~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1511*^*00501*536318230*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151157*536318230*X*005010X279A1~ST*271*536318230*005010X279A1~BHT*0022*11*202608131912000001*20260813*151157~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*202608131912000001*00000000ND~NM1*IL*1*RICHARDSON*NORBERT****MI*UR67059E~N3*485 LENOX AVENUE              15B~N4*NEW YORK*NY*10037~DMG*D8*19521110*M~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20251001~EB*U*IND*30**ELIGIBLE PCP~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*6P*H0423~LS*2120~NM1*P4*2*METROPLUS HEALTH PLAN, INC.*****PI*H0423~N3*160 WATER STREET~N4*NEW YORK*NY*10038~PER*IC*PROVIDER SERVICES*TE*8669860356~LE*2120~EB*R*IND*30~REF*18*7AW6EC1KG61~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*41*536318230~GE*1*536318230~IEA*1*536318230~