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GS*HS*12345*12345*250813*1508*1073904009*X*005010X279A1~
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BHT*0022*13*000000393*2508225*1508~
HL*1**20*1~
NM1*PR*2*UNITED HEALTH CARE MCR ADVANTAGE*****PI*10784~
HL*2*1*21*1~
NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*SUSKIN*MARCIA****MI*117010875~
DMG*D8*19600204*F~
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IEA*1*000000393~