<?xml version=“1.0” encoding=“UTF-8”?> <ClaimResponse xmlns=“hl7.org/fhir”>

      <id value="R3501"/>

      <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/remittance"/>
              <value value="R3501"/>
      </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/1"/>
      </patient>

      <created value="2014-08-16"/>

      <insurer>
              <identifier>
                      <system value="http://www.jurisdiction.org/insurers"/>
                      <value value="555123"/>
              </identifier>
      </insurer>

      <requestor>
              <reference value="Practitioner/1"/>
      </requestor>

      <request>
              <reference value="Claim/100156"/>
      </request>

      <outcome value="error"/>

      <disposition value="Claim could not be processed"/>

      <formCode>
              <coding>
                      <system value="http://terminology.hl7.org/CodeSystem/forms-codes"/>
                      <code value="2"/>
              </coding>
      </formCode>

      <processNote>
              <number value="1"/>
              <type value="display"/>
              <text value="Invalid claim"/>
              <language>
                      <coding>
                              <system value="urn:ietf:bcp:47"/>
                              <code value="en-CA"/>
                      </coding>
              </language>
      </processNote>

      <communicationRequest>
              <reference value="CommunicationRequest/fm-solicit"/>
      </communicationRequest>

      <!--  Detailed error description  -->
      <error>
              <itemSequence value="3"/>
              <detailSequence value="2"/>
              <code>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/adjudication-error"/>
                              <code value="a002"/>
                      </coding>
              </code>
      </error>

</ClaimResponse>