Raw X12 — CIN VN52587U

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1912*|*00501*648344072*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1912*344072*X*005010X279A1~ST*270*4072*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*VN52587U~EQ*30~DTP*291*D8*20260814~SE*13*4072~GE*1*344072~IEA*1*648344072~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1512*^*00501*536411730*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151219*536411730*X*005010X279A1~ST*271*536411730*005010X279A1~BHT*0022*11*202608131912000001*20260813*151219~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*SMIRNOV*ANATOLIY****MI*VN52587U~N3*2400 NOSTRAND AVE             606~N4*BROOKLYN*NY*11210~DMG*D8*19481020*M~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20260601~EB*U*IND*30**ELIGIBLE PCP~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*R*IND*30~REF*18*3WA0AQ6MK07~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*34*536411730~GE*1*536411730~IEA*1*536411730~