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GS*HN*COMEDICAID*DZINESCO*20240620*1200*3*X*005010X214~
ST*277CA*0001*005010X214~
BHT*0085*08*REFNUM003*20240620*1200*TH~
HL*1**20*1~
HL*2*1*21*1~
HL*3*2*19*1~
HL*4*3*PT~
REF*1K*CLAIM099~
REF*EJ*721587149~
STC*A7:19:PR*20240620*U*99.99~
SE*8*0001~
GE*1*1~
IEA*1*000000789~