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

      <id value="MED-00050"/>

      <meta>
  <security>
    <system value="http://terminology.hl7.org/CodeSystem/v3-ActReason"/>
    <code value="HTEST"/>
    <display value="test health data"/>
  </security>
</meta>

      <contained>
              <Patient>
                      <id value="patient-1"/>
                      <name>
                              <use value="official"/>
                              <family value="Ashcraft"/>
                              <given value="Alvina"/>
                      </name>
                      <gender value="female"/>
                      <birthDate value="1954-06-11"/>
                      <address>
                              <use value="home"/>
                              <line value="123 Main Street"/>
                              <city value="Portland"/>
                              <state value="OR"/>
                              <postalCode value="97125"/>
                              <country value="USA"/>
                      </address>
              </Patient>
      </contained>

      <contained>
              <Coverage>
                      <id value="coverage-1"/>

                      <identifier>
                              <system value="http://benefitsinc.com/certificate"/>
                              <value value="10138556"/>
                      </identifier>

                      <status value="active"/>

                      <type>
                              <coding>
                                      <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
                                      <code value="HIP"/>
                                      <display value="health insurance plan policy"/>
                              </coding>
                      </type>

                      <subscriber>
                              <reference value="#patient-1"/>
                      </subscriber>

                      <beneficiary>
                              <reference value="#patient-1"/>
                      </beneficiary>

                      <relationship>
                              <coding>
                                      <code value="self"/>
                              </coding>
                      </relationship>

                      <period>
                              <start value="2015-01-01T00:00:00-07:00"/>
                              <end value="2016-01-01T00:00:00-07:00"/>
                      </period>

                      <payor>
                              <identifier>
                                      <system value="http://www.bindb.com/bin"/>
                                      <value value="123456"/> 
                              </identifier>
                              <display value="Humana Inc."/>
                      </payor>

                      <class>
                              <type>
                                      <coding>
                                              <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
                                              <code value="group"/>
                                      </coding>
                              </type>
                              <value value="80902206"/>
                      </class>

              </Coverage>
      </contained>

      <identifier>
              <system value="http://CedarArmsMedicalCenter.com/claim"/>
              <value value="MED-00050"/>
      </identifier>

      <status value="active"/>

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

      <subType>
              <coding>
                      <system value="https://www.cms.gov/codes/billtype"/>
                      <code value="831"/>
                      <display value="Hospital Outpatient Surgery performed in an Ambulatory ​Surgical Center"/>
              </coding>
      </subType>

      <use value="claim"/>

      <patient>
              <reference value="#patient-1"/>
      </patient>

      <created value="2015-10-16T00:00:00-07:00"/>

      <insurer>
              <identifier>
                      <system value="http://www.bindb.com/bin"/>
                      <value value="123456"/>
              </identifier>
              <display value="Humana Inc."/>
      </insurer>

      <provider>
              <reference value="Organization/1"/>
      </provider>

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

      <payee>
              <type>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
                              <code value="provider"/>
                      </coding>
              </type>
              <party>
                      <reference value="Organization/1"/>
              </party>
      </payee>

      <careTeam>
              <sequence value="1"/>
              <provider>
                      <reference value="Practitioner/example"/>
              </provider>
      </careTeam>

      <supportingInfo>
              <sequence value="1"/>
              <category>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
                              <code value="hospitalized"/>
                      </coding>
              </category>
              <timingPeriod>
                      <start value="2015-10-01T00:00:00-07:00"/>
                      <end value="2015-10-05T00:00:00-07:00"/>
              </timingPeriod>
      </supportingInfo>

      <supportingInfo>
              <sequence value="2"/>
              <category>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
                              <code value="discharge"/>
                      </coding>
              </category>
              <code>
                      <coding>
                              <system value="https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0801.pdf"/>
                              <code value="01"/>
                              <display value="Discharge to Home or Self Care"/>
                      </coding>
              </code>
      </supportingInfo>

      <diagnosis>
              <sequence value="1"/>
              <diagnosisCodeableConcept>
                      <coding>
                              <system value="http://hl7.org/fhir/sid/icd-10"/>
                              <code value="M96.1"/>
                              <display value="Postlaminectomy syndrome"/>
                      </coding>
              </diagnosisCodeableConcept>
      </diagnosis>

      <diagnosis>
              <sequence value="2"/>
              <diagnosisCodeableConcept>
                      <coding>
                              <system value="http://hl7.org/fhir/sid/icd-10"/>
                              <code value="G89.4"/>
                              <display value="Chronic pain syndrome"/>
                      </coding>
              </diagnosisCodeableConcept>
      </diagnosis>

      <diagnosis>
              <sequence value="3"/>
              <diagnosisCodeableConcept>
                      <coding>
                              <system value="http://hl7.org/fhir/sid/icd-10"/>
                              <code value="M53.88"/>
                              <display value="Other specified dorsopathies, sacral and sacrococcygeal region"/>
                      </coding>
              </diagnosisCodeableConcept>
      </diagnosis>

      <diagnosis>
              <sequence value="4"/>
              <diagnosisCodeableConcept>
                      <coding>
                              <system value="http://hl7.org/fhir/sid/icd-10"/>
                              <code value="M47.816"/>
                              <display value="Spondylosis without myelopathy or radiculopathy, lumbar region"/>
                      </coding>
              </diagnosisCodeableConcept>
      </diagnosis>

      <insurance>
              <sequence value="1"/>
              <focal value="true"/>
              <identifier>
                      <system value="http://CedarArmsMedicalCenter.com/claim"/>
                      <value value="MED-00050"/>
              </identifier>           <coverage>
                      <reference value="#coverage-1"/>
              </coverage>
      </insurance>

      <item>
              <sequence value="1"/>
              <careTeamSequence value="1"/>
              <diagnosisSequence value="2"/>
              <diagnosisSequence value="4"/>
              <informationSequence value="1"/>
              <productOrService>
                      <coding>
                              <system value="http://www.ama-assn.org/go/cpt"/>
                              <code value="62264"/>
                              <display value="Surgical Procedures on the Spine and Spinal Cord"/>
                      </coding>
              </productOrService>
              <servicedDate value="2015-10-13"/>
              <locationCodeableConcept>
                      <coding>
                              <system value="https://www.cms.gov/medicare/coding/place-of-service-codes/place_of_service_code_set.html"/>
                              <code value="24"/>
                              <display value="Ambulatory Surgical Center"/>
                      </coding>
              </locationCodeableConcept>
              <unitPrice>
                      <value value="12500.00"/>
                      <currency value="USD"/> 
              </unitPrice> 

              <net>
                      <value value="12500.00"/>
                      <currency value="USD"/> 
              </net> 
      </item>

      <total>
              <value value="12500.00"/>
              <currency value="USD"/> 
      </total>

</Claim>