<?xml version=“1.0” encoding=“UTF-8”?> <ExplanationOfBenefit xmlns=“hl7.org/fhir”>
<id value="EB3500"/> <meta> <security> <system value="http://terminology.hl7.org/CodeSystem/v3-ActReason"/> <code value="HTEST"/> <display value="test health data"/> </security> </meta> <identifier> <system value="http://www.BenefitsInc.com/fhir/explanationofbenefit"/> <value value="987654321"/> </identifier> <status value="active"/> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/claim-type"/> <code value="oral"/> </coding> </type> <use value="claim"/> <patient> <reference value="Patient/pat1"/> </patient> <created value="2014-08-16"/> <enterer> <reference value="Practitioner/1"/> </enterer> <insurer> <reference value="Organization/3"/> </insurer> <provider> <reference value="Practitioner/1"/> </provider> <payee> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/payeetype"/> <code value="provider"/> </coding> </type> <party> <reference value="Organization/2"/> </party> </payee> <facility> <reference value="Location/1"/> </facility> <claim> <reference value="Claim/100150"/> </claim> <claimResponse> <reference value="ClaimResponse/R3500"/> </claimResponse> <outcome value="complete"/> <disposition value="Claim settled as per contract."/> <careTeam> <sequence value="1"/> <provider> <reference value="Practitioner/example"/> </provider> </careTeam> <insurance> <focal value="true"/> <coverage> <reference value="Coverage/9876B1"/> </coverage> </insurance> <item> <sequence value="1"/> <careTeamSequence value="1"/> <productOrService> <coding> <system value="http://terminology.hl7.org/CodeSystem/ex-USCLS"/> <code value="1205"/> </coding> </productOrService> <servicedDate value="2014-08-16"/> <unitPrice> <value value="135.57"/> <currency value="USD"/> </unitPrice> <net> <value value="135.57"/> <currency value="USD"/> </net> <udi> <reference value="Device/example"/> </udi> <encounter> <reference value="Encounter/example"/> </encounter> <adjudication> <category> <coding> <code value="eligible"/> </coding> </category> <amount> <value value="120.00"/> <currency value="USD"/> </amount> </adjudication> <adjudication> <category> <coding> <code value="eligpercent"/> </coding> </category> <value value="0.80"/> </adjudication> <adjudication> <category> <coding> <code value="benefit"/> </coding> </category> <amount> <value value="96.00"/> <currency value="USD"/> </amount> </adjudication> </item> <item> <sequence value="2"/> <careTeamSequence value="1"/> <productOrService> <coding> <code value="group"/> </coding> </productOrService> <servicedDate value="2014-08-16"/> <net> <value value="200.00"/> <currency value="USD"/> </net> <adjudication> <category> <coding> <code value="benefit"/> </coding> </category> <amount> <value value="180.00"/> <currency value="USD"/> </amount> </adjudication> <detail> <sequence value="1"/> <productOrService> <coding> <code value="group"/> </coding> </productOrService> <net> <value value="200.00"/> <currency value="USD"/> </net> <udi> <reference value="Device/example"/> </udi> <adjudication> <category> <coding> <code value="benefit"/> </coding> </category> <amount> <value value="180.00"/> <currency value="USD"/> </amount> </adjudication> <subDetail> <sequence value="1"/> <productOrService> <coding> <system value="http://terminology.hl7.org/CodeSystem/ex-USCLS"/> <code value="1205"/> </coding> </productOrService> <unitPrice> <value value="200.00"/> <currency value="USD"/> </unitPrice> <net> <value value="200.00"/> <currency value="USD"/> </net> <udi> <reference value="Device/example"/> </udi> <adjudication> <category> <coding> <code value="eligible"/> </coding> </category> <amount> <value value="200.00"/> <currency value="USD"/> </amount> </adjudication> <adjudication> <category> <coding> <code value="eligpercent"/> </coding> </category> <value value="0.90"/> </adjudication> <adjudication> <category> <coding> <code value="benefit"/> </coding> </category> <amount> <value value="180.00"/> <currency value="USD"/> </amount> </adjudication> </subDetail> </detail> </item> <total> <category> <coding> <code value="submitted"/> </coding> </category> <amount> <value value="135.57"/> <currency value="USD"/> </amount> </total> <total> <category> <coding> <code value="benefit"/> </coding> </category> <amount> <value value="96.00"/> <currency value="USD"/> </amount> </total>
</ExplanationOfBenefit>