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GS*HS*15004*15004*260123*0801*1457998957*X*005010X279A1~
ST*270*000000295*005010X279A1~
BHT*0022*13*000000295*260123*0801~
HL*1**20*1~
NM1*PR*2*MEDICARE*****PI*06014~
HL*2*1*21*1~
NM1*1P*2*DEVOTION HOME HEALTH CARE, LLC*****XX*1457998957~
HL*3*2*22*0~
NM1*IL*1*CHAVEZ*SERENA JOYCE****MI*2XK6PA1EJ64~
DMG*D8*19540816*F~
DTP*291*RD8*20260123-20260423~
EQ*42~
EQ*30~
SE*14*000000295~
GE*1*295~
IEA*1*000000295~