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GS*HS*60054*60054*251221*1212*1073904009*X*005010X279A1~
ST*270*000001292*005010X279A1~
BHT*0022*13*000001292*2512355*1212~
HL*1**20*1~
NM1*PR*2*AETNA BETTER HEALTH OF VA*****PI*600117~
HL*2*1*21*1~
NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*ZERROUKI*ANIS****MI*975011313877~
DMG*D8*19780302*M~
DTP*291*RD8*20251221-20260321~
EQ*42~
EQ*30~
SE*14*000001292~
GE*1*1292~
IEA*1*000001292~