Raw X12 — CIN WQ86873D

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260813*1913*|*00501*648382653*1*P*:~GS*HS*00ND*EMEDNYREL*20260813*1913*382653*X*005010X279A1~ST*270*2653*005010X279A1~BHT*0022*13*202608131913000001*20260813*1913~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*202608131913000001*00000000ND~NM1*IL*1******MI*WQ86873D~EQ*30~DTP*291*D8*20260814~SE*13*2653~GE*1*382653~IEA*1*648382653~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260813*1512*^*00501*536557130*0*P*|~GS*HB*EMEDNYREL*00ND*20260813*151258*536557130*X*005010X279A1~ST*271*536557130*005010X279A1~BHT*0022*11*202608131913000001*20260813*151258~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*202608131913000001*00000000ND~NM1*IL*1*ANDRE*MARIE****MI*WQ86873D~N3*2037 UTICA AVENUE             2FL~N4*BROOKLYN*NY*11234~DMG*D8*19540922*F~DTP*472*D8*20260813~DTP*346*D8*20260801~DTP*102*D8*20250901~EB*U*IND*30**ELIGIBLE PCP~MSG*S1~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=05~LS*2120~NM1*Y2*2*ANTHEM HP LLC MAP*****PI*YO~N3*1 PENN PLZ FL 35~N4*NEW YORK*NY*101193601~PER*IC*PROVIDER SERVICES*TE*2125635570~LE*2120~EB*B*IND*30***29*0~EB*1*IND*82~EB*R*IND*30~REF*6P*H6988~LS*2120~NM1*P4*2*ANTHEM MEDICARE ADVANTAGE*****PI*H6988~N3*PO BOX 1407 CHURCH STREET STATION~N4*NEW YORK*NY*100081407~PER*IC*PROVIDER SERVICES*TE*8006641504~LE*2120~EB*R*IND*30~REF*18*7QE5EU5CV40~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*536557130~GE*1*536557130~IEA*1*536557130~