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GS*HS*52095*52095*260617*1306*1073904009*X*005010X279A1~
ST*270*000002475*005010X279A1~
BHT*0022*13*000002475*2606168*1306~
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*MASON*GREGORY****MI*23201687~
DMG*D8*19500612*M~
DTP*291*RD8*20260617-20260915~
EQ*42~
EQ*30~
SE*14*000002475~
GE*1*2475~
IEA*1*000002475~

