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GS*HS*10353*10353*260404*1404*1073904009*X*005010X279A1~
ST*270*000001983*005010X279A1~
BHT*0022*13*000001983*260494*1404~
HL*1**20*1~
NM1*PR*2*HUMANA GOLD CHOICE*****PI*6013~
HL*2*1*21*1~
NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*JONES*WAYNE****MI*H51203430~
DMG*D8*19450214*M~
DTP*291*RD8*20260404-20260703~
EQ*42~
EQ*30~
SE*14*000001983~
GE*1*1983~
IEA*1*000001983~

