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GS*HS*52095*52095*251211*1812*1073904009*X*005010X279A1~
ST*270*000001048*005010X279A1~
BHT*0022*13*000001048*2512345*1812~
HL*1**20*1~
NM1*PR*2*KAISER PERMANENTE MEDICARE ADVANTAGE 1*****PI*10403~
HL*2*1*21*1~
NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*CHEA*SIVONG****MI*01119504~
DMG*D8*19550505*F~
DTP*291*RD8*20251211-20260311~
EQ*42~
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IEA*1*000001048~