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GS*HS*12345*12345*260511*1005*1073904009*X*005010X279A1~
ST*270*000002161*005010X279A1~
BHT*0022*13*000002161*2605131*1005~
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*BUENAVENTURA*CONCEPCION****MI*990030349~
DMG*D8*19351208*F~
DTP*291*RD8*20260511-20260809~
EQ*42~
EQ*30~
SE*14*000002161~
GE*1*2161~
IEA*1*000002161~