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GS*HS*52095*52095*260106*0801*1487113239*X*005010X279A1~
ST*270*000038633*005010X279A1~
BHT*0022*13*000038633*260106*0801~
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*JIMINEZ*MANUEL****MI*81347561~
DMG*D8*19520517*M~
DTP*291*RD8*20260106-20260406~
EQ*42~
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SE*14*000038633~
GE*1*38633~
IEA*1*000038633~