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GS*HS***251212*1112*1073904009*X*005010X279A1~
ST*270*000000277*005010X279A1~
BHT*0022*13*000000277*2512346*1112~
HL*1**20*1~
NM1*PR*2*UNITED HEALTH CARE - MD HEALTH CHOICE*****PI*600085~
HL*2*1*21*1~
NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*MUTUMBA *HERBERT ****MI*981911074~
DMG*D8*19560705*M~
DTP*291*RD8*20251212-20260312~
EQ*42~
EQ*30~
SE*14*000000277~
GE*1*277~
IEA*1*000000277~