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GS*HS*10353*10353*251031*1110*1073904009*X*005010X279A1~
ST*270*000000830*005010X279A1~
BHT*0022*13*000000830*2510304*1110~
HL*1**20*1~
NM1*PR*2*HUMANA GOLD CHOICE*****PI*6013~
HL*2*1*21*1~
NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*SMITH*ALENE****MI*H92070537~
DMG*D8*19370716*M~
DTP*291*RD8*20251031-20260129~
EQ*42~
EQ*30~
SE*14*000000830~
GE*1*830~
IEA*1*000000830~