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GS*HS*12345*12345*260313*1703*1073904009*X*005010X279A1~
ST*270*000001859*005010X279A1~
BHT*0022*13*000001859*260372*1703~
HL*1**20*1~
NM1*PR*2*UNITED HEALTH CARE MCR ADVANTAGE*****PI*10784~
HL*2*1*21*1~
NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*ELDER*WALTER****MI*981366085~
DMG*D8*19410315*M~
DTP*291*RD8*20260313-20260611~
EQ*42~
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SE*14*000001859~
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IEA*1*000001859~