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GS*HS*52095*52095*260630*1206*1487113239*X*005010X279A1~
ST*270*000048149*005010X279A1~
BHT*0022*13*000048149*2606181*1206~
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*BUIE*OTHEN****MI*87309431~
DMG*D8*19430519*F~
DTP*291*RD8*20260630-20260928~
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GE*1*48149~
IEA*1*000048149~