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GS*HS*1073904009*1073904009*251205*1112*1073904009*X*005010X279A1~
ST*270*000000966*005010X279A1~
BHT*0022*13*000000966*2512339*1112~
HL*1**20*1~
NM1*PR*2*AETNA MEDICARE ADVANTAGE*****PI*600114~
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*101155257600~
DMG*D8*19481015*F~
DTP*291*RD8*20251205-20260305~
EQ*42~
EQ*30~
SE*14*000000966~
GE*1*966~
IEA*1*000000966~