Raw X12 — CIN XK96815E

ISA*00*          *00*          *ZZ*00ND           *ZZ*EMEDNYREL      *260914*1121*|*00501*384869497*1*P*:~GS*HS*00ND*EMEDNYREL*20260914*1121*869497*X*005010X279A1~ST*270*9497*005010X279A1~BHT*0022*13*202609141121000001*20260914*1121~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*202609141121000001*00000000ND~NM1*IL*1******MI*XK96815E~EQ*30~DTP*291*D8*20260914~SE*13*9497~GE*1*869497~IEA*1*384869497~

ISA*00*          *00*          *ZZ*EMEDNYREL      *ZZ*00ND           *260914*0721*^*00501*245196130*0*P*|~GS*HB*EMEDNYREL*00ND*20260914*072109*245196130*X*005010X279A1~ST*271*245196130*005010X279A1~BHT*0022*11*202609141121000001*20260914*072109~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*202609141121000001*00000000ND~NM1*IL*1*AGISTE*MARIE*Y***MI*XK96815E~N3*1356     E 91ST STREET~N4*BROOKLYN*NY*11236~DMG*D8*19621012*F~DTP*472*D8*20260914~DTP*346*D8*20260901~DTP*102*D8*20260501~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 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*H6988~LS*2120~NM1*P4*2*ANTHEM MEDICARE ADVANTAGE*****PI*H6988~N3*PO BOX 1407 CHURCH STREET STATION~N4*NEW YORK*NY*100081407~PER*IC*PROVIDER SERVICES*TE*8006641504~LE*2120~EB*R*IND*30~REF*18*9Y15TV2AQ62~LS*2120~NM1*P4*2*MEDICARE ABD~LE*2120~SE*42*245196130~GE*1*245196130~IEA*1*245196130~