ISA*00*          *00*          *ZZ*xxxxx          *ZZ*52095          *251205*0912*^*00501*000001104*0*P*>~
GS*HS*52095*52095*251205*0912*1073904009*X*005010X279A1~
ST*270*000001104*005010X279A1~
BHT*0022*13*000001104*2512339*0912~
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*ISLAM*MOHAMMED****MI*13225568~
DMG*D8*19770313*M~
DTP*291*RD8*20251205-20260305~
EQ*42~
EQ*30~
SE*14*000001104~
GE*1*1104~
IEA*1*000001104~