Raw X12 — CIN XF69078X

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260914*1117*|*00501*384672997*1*P*:~GS*HS*00ND*EMEDNYREL*20260914*1117*672997*X*005010X279A1~ST*270*2997*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*XF69078X~EQ*30~DTP*291*D8*20260914~SE*13*2997~GE*1*672997~IEA*1*384672997~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260914*0717*^*00501*244031130*0*P*|~GS*HB*EMEDNYREL*00ND*20260914*071753*244031130*X*005010X279A1~ST*271*244031130*005010X279A1~BHT*0022*11*202609141117000001*20260914*071753~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*CORONADO*EDUARDA****MI*XF69078X~N3*301      DUMONT AVE           2B~N4*BKLYN*NY*11212~DMG*D8*19531013*F~DTP*472*D8*20260914~DTP*346*D8*20260901~DTP*102*D8*20260301~EB*U*IND*30**ELIGIBLE PCP~MSG*PD~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*6P*H3387~LS*2120~NM1*P4*2*UNITEDHEALTHCARE DUAL COMPLETE*****PI*H3387~N3*P O BOX 917~N4*NEW YORK*NY*10269~PER*IC*PROVIDER SERVICES*TE*8005144912~LE*2120~EB*R*IND*30~REF*18*6RX7VQ9EY75~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*43*244031130~GE*1*244031130~IEA*1*244031130~