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GS*HS*.*.*251212*1212*1073904009*X*005010X279A1~
ST*270*000000054*005010X279A1~
BHT*0022*13*000000054*2512346*1212~
HL*1**20*1~
NM1*PR*2*BCBS OF IDAHO*****PI*10119~
HL*2*1*21*1~
NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*VALENZUELA*ADRIANA****MI*YSW101179290~
DMG*D8*19961114*F~
DTP*291*RD8*20251212-20260312~
EQ*42~
EQ*30~
SE*14*000000054~
GE*1*54~
IEA*1*000000054~