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GS*HS*52095*52095*251231*1612*1487113239*X*005010X279A1~
ST*270*000037979*005010X279A1~
BHT*0022*13*000037979*2512365*1612~
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*MADDREY*JANICE****MI*47308575~
DMG*D8*19430619*F~
DTP*291*RD8*20251231-20260331~
EQ*42~
EQ*30~
SE*14*000037979~
GE*1*37979~
IEA*1*000037979~