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GS*HC*10000*10000*20260420*1152*420115201*X*005010X223A2~
ST*837*115201*005010X223A2~
BHT*0019*00*000004*20260420*1104*CH~
NM1*41*2*HOME HEALTH CARES*****46*098765432111~
PER*IC*ADAIR TERRY*TE*5404337146~
NM1*40*2*Medicare PPS*****46*10000~
HL*1**20*1~
PRV*BI*PXC*251E00000X~
NM1*85*2*HOME HEALTH CARES*****XX*1234567891~
N3*579 EAST MARKETSTREETS ~
N4*HARRISONBURG*VA*228011234~
REF*EI*098765432111~
PER*IC*ADAIR TERRY*TE*5404337146~
HL*2*1*22*0~
SBR*P*18*******MA~
NM1*IL*1*MOUSE*MICKEY****MI*3Y98R65AQ13~
N3*123 DISNEY ROAD~
N4*GRUNDY*VA*24614~
DMG*D8*20260420*M~
NM1*PR*2*MEDICARE PPS*****PI*10000~
CLM*179-260420115201*0***32>A>A**A*Y*Y*********~
DTP*434*RD8*20260420-20260420~
DTP*435*DT*202604200000~
CL1*9*6*30~
HI*ABK>I10~
NM1*71*1*HUANG  *JAMES****XX*1154567709~
LX*1~
SV2*0023*HP>1AA11*0.00*UN*1.00~
DTP*472*D8*20260420~
SE*33*115201~
GE*1*420115201~
IEA*1*420115201~