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GS*HS*52095*52095*251028*1110*1487113239*X*005010X279A1~
ST*270*000034521*005010X279A1~
BHT*0022*13*000034521*2510301*1110~
HL*1**20*1~
NM1*PR*2*KAISER MEDICAID*****PI*10403~
HL*2*1*21*1~
NM1*1P*2*HOMECENTRIS HEALTHCARE LLC*****XX*1487113239~
HL*3*2*22*0~
NM1*IL*1*HULL*LORRAINE****MI*37223842~
DMG*D8*19660224*F~
DTP*291*RD8*20251028-20260126~
EQ*42~
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SE*14*000034521~
GE*1*34521~
IEA*1*000034521~