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GS*HS*NA*NA*251031*1610*1073904009*X*005010X279A1~
ST*270*000000832*005010X279A1~
BHT*0022*13*000000832*2510304*1610~
HL*1**20*1~
NM1*PR*2*SENTARA HEALTH PLANS*****PI*54154~
HL*2*1*21*1~
NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*HITE*TANYA****MI*352541748010~
DMG*D8*19730410*F~
DTP*291*RD8*20251031-20260129~
EQ*42~
EQ*30~
SE*14*000000832~
GE*1*832~
IEA*1*000000832~