Raw X12 — CIN WF24778B

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1912*|*00501*648348007*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1912*348007*X*005010X279A1~ST*270*8007*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*WF24778B~EQ*30~DTP*291*D8*20260814~SE*13*8007~GE*1*348007~IEA*1*648348007~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1512*^*00501*536426730*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151223*536426730*X*005010X279A1~ST*271*536426730*005010X279A1~BHT*0022*11*202608131912000001*20260813*151223~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*THOMASON*DERICK****MI*WF24778B~N3*14202 20TH AVE~N4*FLUSHING*NY*11351~DMG*D8*19590827*M~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=66 525~MSG*RECERT MONTH=12~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*WELLLIFE NETWORK INC*****XX*1386817906~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*COORDINATED BEHAVIORAL CARE INC*****XX*1730451071~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*2G89AK8GM46~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*53*536426730~GE*1*536426730~IEA*1*536426730~