ISA*00*          *00*          *ZZ*00             *ZZ*               *261105*0954*U*00501*105095455*0*P*>~
GS*HC*1457998957*3432*20261105*0954*5455*X*005010X222A1~
ST*837*095455*005010X222A1~
BHT*0019*00*000004*20261105*0954*CH~
NM1*41*2*DEVOTION HOME HEALTH CARE, LLC*****46*843850735~
PER*IC*MARIA HUTTO*TE*4804154423~
NM1*40*2*UHC COMMERCIAL PLANS*****46*03432~
HL*1**20*1~
NM1*85*2*DEVOTION HOME HEALTH CARE, LLC*****XX*1457998957~
N3*11201 N TATUM BLVD, SUITE 300~
N4*PHOENIX*AZ*850286039~
REF*EI*843850735~
PER*IC*MARIA HUTTO*TE*4804154423~
HL*2*1*22*0~
SBR*P*18*******CI~
NM1*IL*1*PEKAR*DANIEL****MI*909610988~
N3*2530 E NOVAK WAY, GATE CODE #4597~
N4*PHOENIX*AZ*85042~
DMG*D8*19670712*M~
NM1*PR*2*UHC COMMERCIAL PLANS*****PI*03432~
N3*PO BOX 5290~
N4*KINGSTON*NY*124029999~
CLM*1184-261105095455*7000***12>B>1*Y*A*Y*Y~
REF*G1*Auth not required~
HI*ABK>E11621*ABF>L97518*ABF>A408*ABF>E1169*ABF>M86171*ABF>M86671*ABF>T86821*ABF>I10*ABF>E785*ABF>E1151*ABF>D649*ABF>Z452*ABF>Z792*ABF>Z7984*ABF>Z7985*ABF>Z794~
NM1*DN*1*BLANSFIELD*BRIDGET****XX*1679250393~
NM1*77*2*HOME*****XX*~
N3*11201 N TATUM BLVD, SUITE 300~
N4*PHOENIX*AZ*850286039~
LX*1~
SV1*HC>G0162*700.00*UN*1***1>2>3>4~
DTP*472*D8*20260923~
LX*2~
SV1*HC>G0162*700.00*UN*1***1>2>3>4~
DTP*472*D8*20260925~
LX*3~
SV1*HC>G0162*700.00*UN*1***1>2>3>4~
DTP*472*D8*20260928~
LX*4~
SV1*HC>G0162*700.00*UN*1***1>2>3>4~
DTP*472*D8*20260930~
LX*5~
SV1*HC>G0162*700.00*UN*1***1>2>3>4~
DTP*472*D8*20261002~
LX*6~
SV1*HC>G0162*700.00*UN*1***1>2>3>4~
DTP*472*D8*20261005~
LX*7~
SV1*HC>G0162*700.00*UN*1***1>2>3>4~
DTP*472*D8*20261007~
LX*8~
SV1*HC>G0299*700.00*UN*1***1>2>3>4~
DTP*472*D8*20261016~
LX*9~
SV1*HC>G0299*700.00*UN*1***1>2>3>4~
DTP*472*D8*20261019~
LX*10~
SV1*HC>G0299*700.00*UN*1***1>2>3>4~
DTP*472*D8*20261021~
SE*61*095455~
GE*1*5455~
IEA*1*105095455~