Raw X12 — CIN VP69287U

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1912*|*00501*648335894*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1912*335894*X*005010X279A1~ST*270*5894*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*VP69287U~EQ*30~DTP*291*D8*20260814~SE*13*5894~GE*1*335894~IEA*1*648335894~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1512*^*00501*536378030*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151211*536378030*X*005010X279A1~ST*271*536378030*005010X279A1~BHT*0022*11*202608131912000001*20260813*151211~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*SANCHEZ*CHINA****MI*VP69287U~N3*765 LINCOLN AVE               1F~N4*BROOKLYN*NY*11208~DMG*D8*19940708*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260501~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=08~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*H5599~LS*2120~NM1*P4*2*WELLCARE FIDELIS DUAL ACCESS*****PI*H5599~N3*25-01 JACKSON AVE~N4*LONG ISLAND CITY*NY*11101~PER*IC*PROVIDER SERVICES*TE*8883433547~LE*2120~EB*R*IND*30~REF*18*2AV1ND0AK13~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*536378030~GE*1*536378030~IEA*1*536378030~