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GS*HS*600118*600118*251013*1410*1073904009*X*005010X279A1~
ST*270*000000754*005010X279A1~
BHT*0022*13*000000754*2510286*1410~
HL*1**20*1~
NM1*PR*2*AETNA*****PI*10011~
HL*2*1*21*1~
NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*WILLYERD*TIFFANY****MI*7814906656~
DMG*D8*19730609*F~
DTP*291*RD8*20251013-20260111~
EQ*42~
EQ*30~
SE*14*000000754~
GE*1*754~
IEA*1*000000754~