<?xml version=“1.0” encoding=“UTF-8”?> <ExplanationOfBenefit xmlns=“hl7.org/fhir”>
<id value="EB3501"/> <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="error-1"/> </identifier> <status value="active"/> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/claim-type"/> <code value="oral"/> </coding> </type> <subType> <coding> <system value="http://terminology.hl7.org/CodeSystem/ex-claimsubtype"/> <code value="emergency"/> </coding> </subType> <use value="claim"/> <patient> <reference value="Patient/pat1"/> </patient> <billablePeriod> <start value="2014-02-01"/> <end value="2014-03-01"/> </billablePeriod> <created value="2014-08-16"/> <enterer> <reference value="Practitioner/1"/> </enterer> <insurer> <reference value="Organization/2"/> </insurer> <provider> <reference value="Organization/2"/> </provider> <related> <reference> <system value="http://www.BenefitsInc.com/case-number"/> <value value="23-56Tu-XX-47-20150M14"/> </reference> </related> <prescription> <reference value="MedicationRequest/medrx002"/> </prescription> <originalPrescription> <reference value="MedicationRequest/medrx0301"/> </originalPrescription> <facility> <reference value="Location/1"/> </facility> <claim> <reference value="Claim/100150"/> </claim> <claimResponse> <reference value="ClaimResponse/R3500"/> </claimResponse> <outcome value="error"/> <disposition value="Could not process."/> <supportingInfo> <sequence value="1"/> <category> <coding> <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/> <code value="employmentimpacted"/> </coding> </category> <timingPeriod> <start value="2014-02-14"/> <end value="2014-02-28"/> </timingPeriod> </supportingInfo> <supportingInfo> <sequence value="2"/> <category> <coding> <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/> <code value="hospitalized"/> </coding> </category> <timingPeriod> <start value="2014-02-14"/> <end value="2014-02-16"/> </timingPeriod> </supportingInfo> <procedure> <sequence value="1"/> <date value="2014-02-14"/> <procedureCodeableConcept> <coding> <system value="http://hl7.org/fhir/sid/ex-icd-10-procedures"/> <code value="123001"/> </coding> </procedureCodeableConcept> <udi> <reference value="Device/example"/> </udi> </procedure> <precedence value="2"/> <insurance> <focal value="true"/> <coverage> <reference value="Coverage/9876B1"/> </coverage> </insurance> <accident> <date value="2014-02-14"/> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/> <code value="SPT"/> </coding> </type> <locationReference> <reference value="Location/ph"/> </locationReference> </accident> <total> <category> <coding> <code value="submitted"/> </coding> </category> <amount> <value value="2478.57"/> <currency value="USD"/> </amount> </total> <total> <category> <coding> <code value="benefit"/> </coding> </category> <amount> <value value="0.00"/> <currency value="USD"/> </amount> </total> <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>
</ExplanationOfBenefit>