Raw X12 — CIN KV07509B

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1912*|*00501*648329587*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1912*329587*X*005010X279A1~ST*270*9587*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*KV07509B~EQ*30~DTP*291*D8*20260814~SE*13*9587~GE*1*329587~IEA*1*648329587~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1512*^*00501*536349130*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151205*536349130*X*005010X279A1~ST*271*536349130*005010X279A1~BHT*0022*11*202608131912000001*20260813*151205~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*RODRIGUEZ*VICTOR****MI*KV07509B~N3*600 W 157TH STREET            43~N4*NEW YORK*NY*10032~DMG*D8*19570918*M~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260401~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~MSG*PD~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=04~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*COMMUNITY HLTHCARE NETWORK AI*****XX*1952518078~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*SRH CHN LEAD HEALTH HOME LLC*****XX*1750053948~LE*2120~EB*R*IND*30~REF*6P*H3387~LS*2120~NM1*P4*2*UNITEDHEALTHCARE DUAL COMPLETE*****PI*H3387~N3*P O BOX 917~N4*NEW YORK*NY*10269~PER*IC*PROVIDER SERVICES*TE*8005144912~LE*2120~EB*R*IND*30~REF*18*6YE5ER9PH50~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*53*536349130~GE*1*536349130~IEA*1*536349130~