Raw X12 — CIN UN43584G

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260914*1120*|*00501*384830045*1*P*:~GS*HS*00ND*EMEDNYREL*20260914*1120*830045*X*005010X279A1~ST*270*0045*005010X279A1~BHT*0022*13*202609141120000001*20260914*1120~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*202609141120000001*00000000ND~NM1*IL*1******MI*UN43584G~EQ*30~DTP*291*D8*20260914~SE*13*0045~GE*1*830045~IEA*1*384830045~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260914*0720*^*00501*244440630*0*P*|~GS*HB*EMEDNYREL*00ND*20260914*072030*244440630*X*005010X279A1~ST*271*244440630*005010X279A1~BHT*0022*11*202609141120000001*20260914*072030~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*202609141120000001*00000000ND~NM1*IL*1*YOUNG*ROBERT*G***MI*UN43584G~N3*26417    73RD AVE             1A~N4*GLEN OAKS*NY*11004~DMG*D8*19610809*M~DTP*472*D8*20260914~DTP*346*D8*20260901~DTP*102*D8*20260601~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*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*4TE8K83XV40~LS*2120~NM1*P4*2*MEDICARE ABDQMB~LE*2120~SE*42*244440630~GE*1*244440630~IEA*1*244440630~