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GS*HS*52095*52095*251106*1311*1073904009*X*005010X279A1~
ST*270*000000573*005010X279A1~
BHT*0022*13*000000573*2511310*1311~
HL*1**20*1~
NM1*PR*2*KAISER MEDICAID*****PI*52095~
HL*2*1*21*1~
NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*PINEDA*JAN ANN ALEDRO****MI*21345844~
DMG*D8*19810112*F~
DTP*291*RD8*20251106-20260204~
EQ*42~
EQ*30~
SE*14*000000573~
GE*1*573~
IEA*1*000000573~