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GS*HS*52095*52095*260408*1704*1487113239*X*005010X279A1~
ST*270*000042667*005010X279A1~
BHT*0022*13*000042667*260498*1704~
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*MELVIN*THOMAS****MI*611033511~
DMG*D8*19530730*M~
DTP*291*RD8*20260408-20260707~
EQ*42~
EQ*30~
SE*14*000042667~
GE*1*42667~
IEA*1*000042667~