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GS*HS*10000*10000*251103*1411*1487113239*X*005010X279A1~
ST*270*000031375*005010X279A1~
BHT*0022*13*000031375*2511307*1411~
HL*1**20*1~
NM1*PR*2*MEDICARE PPS*****PI*10000~
HL*2*1*21*1~
NM1*1P*2*HOMECENTRIS HEALTHCARE LLC*****XX*1487113239~
HL*3*2*22*0~
NM1*IL*1*CLARK*BRENDA****MI*6FF9H75DX11~
DMG*D8*19610921*F~
DTP*291*RD8*20251103-20260201~
EQ*42~
EQ*30~
SE*14*000031375~
GE*1*31375~
IEA*1*000031375~