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GS*HS*52095*52095*250905*0809*1487113239*X*005010X279A1~
ST*270*000031794*005010X279A1~
BHT*0022*13*000031794*2509248*0809~
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*BURRELL*GLADYS****MI*64107350~
DMG*D8*19520307*F~
DTP*291*RD8*20250905-20251204~
EQ*42~
EQ*30~
SE*14*000031794~
GE*1*31794~
IEA*1*000031794~