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GS*HS*52095*52095*260919*0809*1073904009*X*005010X279A1~
ST*270*000002759*005010X279A1~
BHT*0022*13*000002759*2609262*0809~
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*HERRERA*MARIA****MI*54179444~
DMG*D8*19510531*M~
DTP*291*RD8*20260919-20261218~
EQ*42~
EQ*30~
SE*14*000002759~
GE*1*2759~
IEA*1*000002759~

