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GS*HS*52095*52095*251212*1112*1073904009*X*005010X279A1~
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BHT*0022*13*000001076*2512346*1112~
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*WILLIAMS*MARY****MI*191289386~
DMG*D8*19401005*F~
DTP*291*RD8*20251212-20260312~
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IEA*1*000001076~