Raw X12 — CIN VG19373Q

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260914*1118*|*00501*384709933*1*P*:~GS*HS*00ND*EMEDNYREL*20260914*1118*709933*X*005010X279A1~ST*270*9933*005010X279A1~BHT*0022*13*202609141118000001*20260914*1118~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*202609141118000001*00000000ND~NM1*IL*1******MI*VG19373Q~EQ*30~DTP*291*D8*20260914~SE*13*9933~GE*1*709933~IEA*1*384709933~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260914*0718*^*00501*244074130*0*P*|~GS*HB*EMEDNYREL*00ND*20260914*071830*244074130*X*005010X279A1~ST*271*244074130*005010X279A1~BHT*0022*11*202609141118000001*20260914*071830~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*202609141118000001*00000000ND~NM1*IL*1*SERRANOREYES*ISMAEL****MI*VG19373Q~N3*3137     MILES AVE~N4*BRONX*NY*10465~DMG*D8*19450929*M~DTP*472*D8*20260914~DTP*346*D8*20260901~DTP*102*D8*20260101~EB*U*IND*30**ELIGIBLE PCP~MSG*CF~MSG*CNTY CD=66 5H9~MSG*RECERT MONTH=10~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*H8432~LS*2120~NM1*P4*2*EMPIRE MEDIBLUE CORE*****PI*H8432~N3*EMPIRE MEDIBLUE*PO BOX 1407 CHURCH STREET STATION~N4*NEW YORK*NY*100081407~PER*IC*PROVIDER SERVICES*TE*8557311090~LE*2120~EB*R*IND*30~REF*18*1FP8C25QP41~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*244074130~GE*1*244074130~IEA*1*244074130~