Raw X12 — CIN PW66773P

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260914*1117*|*00501*384642956*1*P*:~GS*HS*00ND*EMEDNYREL*20260914*1117*642956*X*005010X279A1~ST*270*2956*005010X279A1~BHT*0022*13*202609141117000001*20260914*1117~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*202609141117000001*00000000ND~NM1*IL*1******MI*PW66773P~EQ*30~DTP*291*D8*20260914~SE*13*2956~GE*1*642956~IEA*1*384642956~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260914*0717*^*00501*243987630*0*P*|~GS*HB*EMEDNYREL*00ND*20260914*071723*243987630*X*005010X279A1~ST*271*243987630*005010X279A1~BHT*0022*11*202609141117000001*20260914*071723~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*202609141117000001*00000000ND~NM1*IL*1*CASTROCHICA*ANA*C***MI*PW66773P~N3*3750     81ST ST              3D~N4*JACKSON HEIGHTS*NY*11372~DMG*D8*19590220*F~DTP*472*D8*20260914~DTP*346*D8*20260901~DTP*102*D8*20260201~EB*U*IND*30**ELIGIBLE PCP~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=10~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*ETRBJ3386148~REF*6P*720902MM1A~LS*2120~NM1*P4*2*ANTHEM BC/BS (EMPIRE)*****PI*12~N3*PO BOX 1407 CHURCH ST STATION*ATTN  CLAIMS DEPT~N4*NEW YORK*NY*100081407~PER*IC*PROVIDER SERVICES*TE*8005235978~LE*2120~EB*R*IND*30~REF*18*00338614801~REF*6P*CT132BJ21~LS*2120~NM1*P4*2*OPTUM RX*****PI*ORX~N3*PO BOX 8082~N4*WAUSAU*WI*544028082~PER*IC*PROVIDER SERVICES*TE*8002071561~LE*2120~EB*R*IND*30~REF*18*3GA9W91XM18~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*52*243987630~GE*1*243987630~IEA*1*243987630~