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GS*HS*NA*NA*260818*1308*1073904009*X*005010X279A1~
ST*270*000002695*005010X279A1~
BHT*0022*13*000002695*2608230*1308~
HL*1**20*1~
NM1*PR*2*MAGELLAN MEDICAID*****PI*600105~
HL*2*1*21*1~
NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*STAHL*TAYLOR****MI*VAQ727327688~
DMG*D8*19690419*M~
DTP*291*RD8*20260818-20261116~
EQ*42~
EQ*30~
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IEA*1*000002695~