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GS*HS*52095*52095*260203*1902*1073904009*X*005010X279A1~
ST*270*000001459*005010X279A1~
BHT*0022*13*000001459*260234*1902~
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*JOHNSON*HERMAN****MI*68298939~
DMG*D8*19550506*M~
DTP*291*RD8*20260203-20260504~
EQ*42~
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IEA*1*000001459~