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GS*HS***260313*1003*1043536642*X*005010X279A1~
ST*270*000000058*005010X279A1~
BHT*0022*13*000000058*260372*1003~
HL*1**20*1~
NM1*PR*2*VA FEE BASIS PROGRAMS PER VISIT OPTUM*****PI*VACCN~
HL*2*1*21*1~
NM1*1P*2*MEDI LINK HEALTH SERVICES LLC*****XX*1043536642~
HL*3*2*22*0~
NM1*IL*1*ROBINSON*ROBERT****MI*1015766591V998362~
DMG*D8*19610403*M~
DTP*291*RD8*20260313-20260611~
EQ*42~
EQ*30~
SE*14*000000058~
GE*1*58~
IEA*1*000000058~