ISA*00*          *00*          *ZZ*xxxxx          *ZZ*52095          *250924*1809*^*00501*000000614*0*P*>~
GS*HS*52095*52095*250924*1809*1073904009*X*005010X279A1~
ST*270*000000614*005010X279A1~
BHT*0022*13*000000614*2509267*1809~
HL*1**20*1~
NM1*PR*2*KAISER MEDICAID*****PI*52095~
HL*2*1*21*1~
NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*MALDONALDO*RONNER****MI*651033074~
DMG*D8*19820503*M~
DTP*291*RD8*20250924-20251223~
EQ*42~
EQ*30~
SE*14*000000614~
GE*1*614~
IEA*1*000000614~

