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

      <id value="960151"/>

      <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://happyhospital.com/claim"/>
              <value value="96123451"/>
      </identifier>

      <status value="active"/>

      <type>
              <coding>
                      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
                      <code value="institutional"/>
              </coding>
      </type>

      <use value="claim"/>

      <patient>
              <reference value="Patient/1"/>
      </patient>

      <billablePeriod>
              <start value="2014-08-15"/>
              <end value="2014-08-16"/>
      </billablePeriod>

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

      <enterer>
              <identifier>
                      <system value="http://jurisdiction.org/facilities/HOSP1234/users"/>
                      <value value="UC1234"/>
              </identifier>
      </enterer>

      <insurer>
              <reference value="Organization/2"/>
      </insurer>

      <provider>
              <identifier>
                      <system value="http://npid.org/providerid"/>
                      <value value="NJ12345"/>
              </identifier>
      </provider>

      <priority>
              <coding>
                      <code value="normal"/>
              </coding>
      </priority>

      <payee>
              <type>
                      <coding>
                              <code value="provider"/>
                      </coding>
              </type>
      </payee>

      <facility>
              <identifier>
                      <system value="http://jurisdiction.org/facilities"/>
                      <value value="HOSP1234"/>
              </identifier>
      </facility>

      <careTeam>
              <sequence value="1"/>
              <provider>
                      <reference value="Practitioner/example"/>
              </provider>
              <responsible value="true"/>
              <role>
                      <coding>
                              <system value="http://example.org/fhir/CodeSystem/claim-careteamrole"/>
                              <code value="primary"/>
                      </coding>
              </role>
              <qualification>
                      <coding>
                              <system value="http://example.org/fhir/CodeSystem/provider-qualification"/>
                              <code value="physician"/>
                      </coding>
              </qualification>
      </careTeam>

      <supportingInfo>
              <sequence value="1"/>
              <category>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
                              <code value="employmentimpacted"/>
                      </coding>
              </category>
              <timingPeriod>
                      <start value="2014-08-16"/>
                      <end value="2014-08-16"/>
              </timingPeriod>
      </supportingInfo>

      <supportingInfo>
              <sequence value="2"/>
              <category>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
                              <code value="hospitalized"/>
                      </coding>
              </category>
              <timingPeriod>
                      <start value="2014-08-15"/>
                      <end value="2014-08-16"/>
              </timingPeriod>
      </supportingInfo>

      <diagnosis>
              <sequence value="1"/>
              <diagnosisCodeableConcept>
                      <coding>
                              <code value="654456"/>
                      </coding>
              </diagnosisCodeableConcept>
              <type>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/ex-diagnosistype"/>
                              <code value="admitting"/>
                      </coding>
              </type>
              <packageCode>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/ex-diagnosisrelatedgroup"/>
                              <code value="400"/>
                              <display value="Head trauma - concussion"/>
                      </coding>
              </packageCode>
      </diagnosis>

      <insurance>
              <sequence value="1"/>
              <focal value="true"/>
              <coverage>
                      <reference value="Coverage/9876B1"/>
              </coverage>
              <businessArrangement value="BA987123"/>
              <preAuthRef value="PA2014G56473"/>
      </insurance>

      <accident>
              <date value="2014-07-09"/>
              <type>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/v3-ActIncidentCode"/>
                              <code value="SPT"/>
                              <display value="Sporting Accident"/>
                      </coding>
              </type>
              <locationAddress>
                      <text value="Grouse Mountain Ski Hill"/>
              </locationAddress>
      </accident>

      <item>
              <sequence value="1"/>
              <careTeamSequence value="1"/>
              <productOrService>
                      <coding>
                              <system value="http://hl7.org/fhir/ex-serviceproduct"/>
                              <code value="exam"/> 
                      </coding>
              </productOrService>
              <servicedDate value="2014-08-16"/>
              <unitPrice>
                      <value value="125.00"/>
                      <currency value="USD"/> 
              </unitPrice> 
              <net>
                      <value value="125.00"/>
                      <currency value="USD"/> 
              </net> 
      </item>

      <total>
              <value value="125.00"/>
              <currency value="USD"/>  
      </total>

</Claim>