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GS*HS*3432*3432*250825*1208*1457998957*X*005010X279A1~
ST*270*000000109*005010X279A1~
BHT*0022*13*000000109*2508237*1208~
HL*1**20*1~
NM1*PR*2*UHC AHCCCS/ALTCS*****PI*3432~
HL*2*1*21*1~
NM1*1P*2*DEVOTION HOME HEALTH CARE, LLC*****XX*1457998957~
HL*3*2*22*0~
NM1*IL*1*RIVERA*RAYMOND****MI*A00111312~
DMG*D8*19510303*M~
DTP*291*RD8*20250825-20251123~
EQ*42~
EQ*30~
SE*14*000000109~
GE*1*109~
IEA*1*000000109~