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GS*HS***250929*1209*1073904009*X*005010X279A1~
ST*270*000000620*005010X279A1~
BHT*0022*13*000000620*2509272*1209~
HL*1**20*1~
NM1*PR*2*ANTHEM MEDICARE ADVANTAGE*****PI*10115~
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NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*NASSAR*RAFEEKA****MI*YTW118W05665~
DMG*D8*19480315*F~
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IEA*1*000000620~