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GS*HS*52095*52095*250904*1309*1487113239*X*005010X279A1~
ST*270*000026687*005010X279A1~
BHT*0022*13*000026687*2509247*1309~
HL*1**20*1~
NM1*PR*2*KAISER PERMANENTE MEDICARE ADVANTAGE 1*****PI*10403~
HL*2*1*21*1~
NM1*1P*2*HOMECENTRIS HEALTHCARE LLC*****XX*1487113239~
HL*3*2*22*0~
NM1*IL*1*LOAR*JOHN****MI*22218256~
DMG*D8*19330328*M~
DTP*291*RD8*20250904-20251203~
EQ*42~
EQ*30~
SE*14*000026687~
GE*1*26687~
IEA*1*000026687~