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

      <id value="EB3500"/>

      <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="987654321"/>
      </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/pat1"/>
      </patient>

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

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

      <insurer>
              <reference value="Organization/3"/>
      </insurer>

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

      <payee>
              <type>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
                              <code value="provider"/>
                      </coding>
              </type>
              <party>
                      <reference value="Organization/2"/>
              </party>
      </payee>

      <facility>
              <reference value="Location/1"/>
      </facility>

      <claim>
              <reference value="Claim/100150"/>
      </claim>

      <claimResponse>
              <reference value="ClaimResponse/R3500"/>
      </claimResponse> 

      <outcome value="complete"/>

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

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

      <insurance>
              <focal value="true"/>
              <coverage>
                      <reference value="Coverage/9876B1"/>
              </coverage>
      </insurance>

      <item>
              <sequence value="1"/>
              <careTeamSequence value="1"/>
              <productOrService>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/ex-USCLS"/>
                              <code value="1205"/>
                      </coding>
              </productOrService>
              <servicedDate value="2014-08-16"/>
              <unitPrice>
                      <value value="135.57"/>
                      <currency value="USD"/> 
              </unitPrice> 
              <net>
                      <value value="135.57"/>
                      <currency value="USD"/> 
              </net> 
              <udi>
                      <reference value="Device/example"/>
              </udi>
              <encounter>
                      <reference value="Encounter/example"/>
              </encounter>
              <adjudication>
                      <category>
                              <coding>
                                      <code value="eligible"/>
                              </coding>
                      </category>
                      <amount>
                              <value value="120.00"/>
                              <currency value="USD"/> 
                      </amount> 
              </adjudication>
              <adjudication>
                      <category>
                              <coding>
                                      <code value="eligpercent"/>
                              </coding>
                      </category>
                      <value value="0.80"/>
              </adjudication>
              <adjudication>
                      <category>
                              <coding>
                                      <code value="benefit"/>
                              </coding>
                      </category>
                      <amount>
                              <value value="96.00"/>
                              <currency value="USD"/> 
                      </amount> 
              </adjudication>
      </item>

      <item>
              <sequence value="2"/>
              <careTeamSequence value="1"/>
              <productOrService>
                      <coding>
                              <code value="group"/>
                      </coding>
              </productOrService>
              <servicedDate value="2014-08-16"/>
              <net>
                      <value value="200.00"/>
                      <currency value="USD"/> 
              </net> 
              <adjudication>
                      <category>
                              <coding>
                                      <code value="benefit"/>
                              </coding>
                      </category>
                      <amount>
                              <value value="180.00"/>
                              <currency value="USD"/> 
                      </amount> 
              </adjudication>
              <detail>
                      <sequence value="1"/>
                      <productOrService>
                              <coding>
                                      <code value="group"/>
                              </coding>
                      </productOrService>
                      <net>
                              <value value="200.00"/>
                              <currency value="USD"/> 
                      </net> 
                      <udi>
                              <reference value="Device/example"/>
                      </udi>
                      <adjudication>
                              <category>
                                      <coding>
                                              <code value="benefit"/>
                                      </coding>
                              </category>
                              <amount>
                                      <value value="180.00"/>
                                      <currency value="USD"/> 
                              </amount> 
                      </adjudication>
                      <subDetail>
                              <sequence value="1"/>
                              <productOrService>
                                      <coding>
                                              <system value="http://terminology.hl7.org/CodeSystem/ex-USCLS"/>
                                              <code value="1205"/>
                                      </coding>
                              </productOrService>
                              <unitPrice>
                                      <value value="200.00"/>
                                      <currency value="USD"/> 
                              </unitPrice> 
                              <net>
                                      <value value="200.00"/>
                                      <currency value="USD"/> 
                              </net> 
                              <udi>
                                      <reference value="Device/example"/>
                              </udi>
                              <adjudication>
                                      <category>
                                              <coding>
                                                      <code value="eligible"/>
                                              </coding>
                                      </category>
                                      <amount>
                                              <value value="200.00"/>
                                              <currency value="USD"/> 
                                      </amount> 
                              </adjudication>
                              <adjudication>
                                      <category>
                                              <coding>
                                                      <code value="eligpercent"/>
                                              </coding>
                                      </category>
                                      <value value="0.90"/>
                              </adjudication>
                              <adjudication>
                                      <category>
                                              <coding>
                                                      <code value="benefit"/>
                                              </coding>
                                      </category>
                                      <amount>
                                              <value value="180.00"/>
                                              <currency value="USD"/> 
                                      </amount> 
                              </adjudication>
                      </subDetail>
              </detail>
      </item>

      <total>
              <category>
                      <coding>
                              <code value="submitted"/>
                      </coding>
              </category>
              <amount>
                      <value value="135.57"/>
                      <currency value="USD"/> 
              </amount> 
      </total>

      <total>
              <category>
                      <coding>
                              <code value="benefit"/>
                      </coding>
              </category>
              <amount>
                      <value value="96.00"/>
                      <currency value="USD"/> 
              </amount> 
      </total>

</ExplanationOfBenefit>