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GS*HS*52095*52095*251004*1310*1073904009*X*005010X279A1~
ST*270*000000667*005010X279A1~
BHT*0022*13*000000667*2510277*1310~
HL*1**20*1~
NM1*PR*2*KAISER PERMANENTE MEDICARE ADVANTAGE 1*****PI*10403~
HL*2*1*21*1~
NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*MACHADO RIVERA*MIRIAM****MI*23176204~
DMG*D8*19520612*M~
DTP*291*RD8*20251004-20260102~
EQ*42~
EQ*30~
SE*14*000000667~
GE*1*667~
IEA*1*000000667~

