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GS*HS*12345*12345*251107*1511*1073904009*X*005010X279A1~
ST*270*000000557*005010X279A1~
BHT*0022*13*000000557*2511311*1511~
HL*1**20*1~
NM1*PR*2*UNITED HEALTH CARE MCR ADVANTAGE*****PI*10784~
HL*2*1*21*1~
NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*HALLIDAY*MICHAEL****MI*968206894~
DMG*D8*19480922*M~
DTP*291*RD8*20251107-20260205~
EQ*42~
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GE*1*557~
IEA*1*000000557~