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GS*HS*60054*60054*251112*0911*1073904009*X*005010X279A1~
ST*270*000000966*005010X279A1~
BHT*0022*13*000000966*2511316*0911~
HL*1**20*1~
NM1*PR*2*AETNA BETTER HEALTH OF VA*****PI*600117~
HL*2*1*21*1~
NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*DELOATCH*LEILA****MI*000000~
DMG*D8*19390506*F~
DTP*291*RD8*20251112-20260210~
EQ*42~
EQ*30~
SE*14*000000966~
GE*1*966~
IEA*1*000000966~