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

      <id value="R3503"/>

      <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="R3503"/>
      </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="Organization/1"/>
      </requestor>

      <request>
              <identifier>
                      <system value="http://happyvalley.com/claim"/>
                      <value value="12346"/>
              </identifier>
      </request>

      <outcome value="complete"/>

      <disposition value="Claim settled as per contract."/>

      <payeeType>
              <coding>
                      <system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
                      <code value="provider"/>
              </coding>
      </payeeType>

      <!--  Adjudication details  -->

      <item> <!--  Pays for a claim package code with two actual codes with adjudication details  -->

              <itemSequence value="1"/> 

              <adjudication>
                      <category>
                              <coding>
                                      <code value="eligible"/>
                              </coding>
                      </category>
                      <amount>
                              <value value="0.00"/>
                              <currency value="USD"/>
                      </amount>
              </adjudication>
              <adjudication>
                      <category>
                              <coding>
                                      <code value="benefit"/>
                              </coding>
                      </category>
                      <amount>
                              <value value="0.00"/>
                              <currency value="USD"/>
                      </amount>       
              </adjudication>

      </item>

      <item>
              <itemSequence value="2"/> 

              <adjudication>
                      <category>
                              <coding>
                                      <code value="eligible"/>
                              </coding>
                      </category>
                      <amount>
                              <value value="105.00"/>
                              <currency value="USD"/>
                      </amount>
              </adjudication>

              <adjudication>
                      <category>
                              <coding>
                                      <code value="eligpercent"/>
                              </coding>
                      </category>
                      <value value="80.00"/>
              </adjudication>

              <adjudication>
                      <category>
                              <coding>
                                      <code value="benefit"/>
                              </coding>
                      </category>
                      <amount>
                              <value value="84.00"/>
                              <currency value="USD"/>
                      </amount>       
              </adjudication>

      </item>

      <item>
              <itemSequence value="3"/> 

              <adjudication>
                      <category>
                              <coding>
                                      <code value="eligible"/>
                              </coding>
                      </category>
                      <amount>
                              <value value="750.00"/>
                              <currency value="USD"/>
                      </amount>
              </adjudication>

              <adjudication>
                      <category>
                              <coding>
                                      <code value="eligpercent"/>
                              </coding>
                      </category>
                      <value value="80.00"/>
              </adjudication>

              <adjudication>
                      <category>
                              <coding>
                                      <code value="benefit"/>
                              </coding>
                      </category>
                      <amount>
                              <value value="600.00"/>
                              <currency value="USD"/>
                      </amount>       
              </adjudication>

              <detail>
                      <detailSequence value="1"/> 

                      <adjudication>
                              <category>
                                      <coding>
                                              <code value="eligible"/>
                                      </coding>
                              </category>
                              <amount>
                                      <value value="750.00"/>
                                      <currency value="USD"/>
                              </amount>
                      </adjudication>

                      <adjudication>
                              <category>
                                      <coding>
                                              <code value="eligpercent"/>
                                      </coding>
                              </category>
                              <value value="80.00"/>
                      </adjudication>

                      <adjudication>
                              <category>
                                      <coding>
                                              <code value="benefit"/>
                                      </coding>
                              </category>
                              <amount>
                                      <value value="600.00"/>
                                      <currency value="USD"/>
                              </amount>       
                      </adjudication>

              </detail>
              <detail>  <!--  See the addItem.detail below  -->
                      <detailSequence value="2"/> 

                      <adjudication>
                              <category>
                                      <coding>
                                              <code value="eligible"/>
                                      </coding>
                              </category>
                              <amount>
                                      <value value="0.00"/>
                                      <currency value="USD"/>
                              </amount>
                      </adjudication>

                      <adjudication>
                              <category>
                                      <coding>
                                              <code value="benefit"/>
                                      </coding>
                              </category>
                              <amount>
                                      <value value="0.00"/>
                                      <currency value="USD"/>
                              </amount>       
                      </adjudication>

              </detail>
      </item>

      <!--  Pays for a claim package code (1200) with two actual codes (1101, 2141) with adjudication details  -->
      <addItem>
              <itemSequence value="1"/> 
              <productOrService>
                      <coding>
                              <system value="http://example.org/fhir/oralservicecodes"/>
                              <code value="1101"/>
                      </coding>
              </productOrService>
              <modifier>
                      <coding>
                              <system value="http://example.org/fhir/modifiers"/>
                              <code value="x"/>
                              <display value="None"/>
                      </coding>
              </modifier>
              <net>
                      <value value="135.57"/>
                      <currency value="USD"/>
              </net>
              <noteNumber value="101"/>
              <adjudication>
                      <category>
                              <coding>
                                      <code value="eligible"/>
                              </coding>
                      </category>
                      <amount>
                              <value value="100.00"/>
                              <currency value="USD"/>
                      </amount>
              </adjudication>

              <adjudication>
                      <category>
                              <coding>
                                      <code value="copay"/>
                              </coding>
                      </category>
                      <amount>
                              <value value="10.00"/>
                              <currency value="USD"/>
                      </amount>  
              </adjudication>

              <adjudication>
                      <category>
                              <coding>
                                      <code value="eligpercent"/>
                              </coding>
                      </category>
                      <value value="80.00"/>
              </adjudication>
              <adjudication>
                      <category>
                              <coding>
                                      <code value="benefit"/>
                              </coding>
                      </category>
                      <reason>
                              <coding>
                                      <system value="http://terminology.hl7.org/CodeSystem/adjudication-reason"/>
                                      <code value="ar002"/>
                                      <display value="Plan Limit Reached"/>
                                      <!--  should have paid 100.47  -->
                              </coding>
                      </reason>
                      <amount>
                              <value value="72.00"/>
                              <currency value="USD"/>
                      </amount>       
              </adjudication>

      </addItem>
      <addItem>
              <itemSequence value="1"/> 
              <productOrService>
                      <coding>
                              <system value="http://example.org/fhir/oralservicecodes"/>
                              <code value="2141"/>
                              <display value="Radiograph, bytewing"/>
                      </coding>
              </productOrService>
              <net>
                      <value value="35.57"/>
                      <currency value="USD"/>
              </net>
              <adjudication>
                      <category>
                              <coding>
                                      <code value="eligible"/>
                              </coding>
                      </category>
                      <amount>
                              <value value="35.57"/>
                              <currency value="USD"/>
                      </amount>
              </adjudication>

              <adjudication>
                      <category>
                              <coding>
                                      <code value="eligpercent"/>
                              </coding>
                      </category>
                      <value value="80.00"/>
              </adjudication>
              <adjudication>
                      <category>
                              <coding>
                                      <code value="benefit"/>
                              </coding>
                      </category>
                      <amount>
                              <value value="28.47"/>
                              <currency value="USD"/>
                      </amount>       
              </adjudication>
      </addItem>

      <!--  Pays for a claim package code (1200) with two actual codes (1101, 2141) with adjudication details  -->
      <addItem>
              <itemSequence value="3"/> 
              <detailSequence value="2"/>
              <productOrService>
                      <coding>
                              <system value="http://example.org/fhir/oralservicecodes"/>
                              <code value="expense"/>
                      </coding>
              </productOrService>
              <modifier>
                      <coding>
                              <system value="http://example.org/fhir/modifiers"/>
                              <code value="x"/>
                              <display value="None"/>
                      </coding>
              </modifier>
              <net>
                      <value value="350.00"/>
                      <currency value="USD"/>
              </net>
              <noteNumber value="101"/>
              <adjudication>
                      <category>
                              <coding>
                                      <code value="eligible"/>
                              </coding>
                      </category>
                      <amount>
                              <value value="350.00"/>
                              <currency value="USD"/>
                      </amount>
              </adjudication>

              <adjudication>
                      <category>
                              <coding>
                                      <code value="eligpercent"/>
                              </coding>
                      </category>
                      <value value="80.00"/>
              </adjudication>
              <adjudication>
                      <category>
                              <coding>
                                      <code value="benefit"/>
                              </coding>
                      </category>
                      <amount>
                              <value value="270.00"/>
                              <currency value="USD"/>
                      </amount>       
              </adjudication>

      </addItem>

      <total>
              <category>
                      <coding>
                              <code value="submitted"/>
                      </coding>
              </category>
              <amount>
                      <value value="1340.57"/>
                      <currency value="USD"/> 
              </amount> 
      </total>

      <total>
              <category>
                      <coding>
                              <code value="benefit"/>
                      </coding>
              </category>
              <amount>
                      <value value="1054.47"/>
                      <currency value="USD"/> 
              </amount> 
      </total>

      <!--  Payment details  -->
      <payment>
              <type>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/ex-paymenttype"/>
                              <code value="complete"/>
                      </coding>
              </type> 

              <date value="2014-08-31"/>

              <amount>
                      <value value="100.47"/>
                      <currency value="USD"/>
              </amount>       

              <identifier>
                      <system value="http://www.BenefitsInc.com/fhir/paymentidentifier"/>
                      <value value="201408-2-15507"/>
              </identifier>   
      </payment>

      <processNote>
              <number value="101"/>
              <type value="print"/>
              <text value="Package codes are not permitted. Codes replaced by Insurer."/>
              <language>
                      <coding>
                              <system value="urn:ietf:bcp:47"/>
                              <code value="en-CA"/>
                      </coding>
              </language>
      </processNote>

</ClaimResponse>