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GS*HS*52095*52095*260904*1609*1487113239*X*005010X279A1~
ST*270*000050417*005010X279A1~
BHT*0022*13*000050417*2609247*1609~
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*HALLOCK*MARY****MI*63115300~
DMG*D8*19360117*F~
DTP*291*RD8*20260904-20261203~
EQ*42~
EQ*30~
SE*14*000050417~
GE*1*50417~
IEA*1*000050417~