Raw X12 — CIN SW00467F

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260914*1119*|*00501*384776407*1*P*:~GS*HS*00ND*EMEDNYREL*20260914*1119*776407*X*005010X279A1~ST*270*6407*005010X279A1~BHT*0022*13*202609141119000001*20260914*1119~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*202609141119000001*00000000ND~NM1*IL*1******MI*SW00467F~EQ*30~DTP*291*D8*20260914~SE*13*6407~GE*1*776407~IEA*1*384776407~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260914*0719*^*00501*244164930*0*P*|~GS*HB*EMEDNYREL*00ND*20260914*071936*244164930*X*005010X279A1~ST*271*244164930*005010X279A1~BHT*0022*11*202609141119000001*20260914*071936~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*202609141119000001*00000000ND~NM1*IL*1*RAMOSCASTILLO*MELVIN*A***MI*SW00467F~N3*649      EVERGREEN AVENUE     2~N4*BROOKLYN*NY*11207~DMG*D8*19640228*M~DTP*472*D8*20260914~DTP*346*D8*20260901~DTP*102*D8*20260501~EB*U*IND*30**ELIGIBLE PCP~MSG*A1~MSG*A2~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*W*IND*CQ~LS*2120~NM1*Y2*2*METRO CARE MANAGEMENT LLC*****XX*1922565118~LE*2120~EB*W*IND*CQ~LS*2120~NM1*Y2*2*COORDINATED BEHAVIORAL CARE INC*****XX*1730451071~LE*2120~EB*R*IND*30~REF*18*1QH4YR5KT79~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*45*244164930~GE*1*244164930~IEA*1*244164930~