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

      <id value="760151"/>

      <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://happypharma.com/claim"/>
              <value value="7612345"/>
      </identifier>

      <status value="active"/>

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

      <use value="claim"/>

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

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

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

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

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

      <prescription>
              <reference value="http://pharmacy.org/MedicationRequest/AB1234G"/>
      </prescription>

      <originalPrescription>
              <reference value="http://pharmacy.org/MedicationRequest/AB1202B"/>
      </originalPrescription>

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

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

      <supportingInfo>
              <sequence value="1"/>
              <category>
                      <coding>
                              <code value="pharmacyrefill"/>
                      </coding>
              </category>
              <code>
                      <coding>
                              <system value="http://example.org/fhir/CodeSystem/pharmacy-refill"/>
                              <code value="new"/>
                      </coding>
              </code> 
      </supportingInfo>

      <supportingInfo>
              <sequence value="2"/>
              <category>
                      <coding>
                              <code value="pharmacyinformation"/>
                      </coding>
              </category>
              <code>
                      <coding>
                              <system value="http://example.org/fhir/CodeSystem/pharmacy-information"/>
                              <code value="refillsremaining"/>
                      </coding>
              </code> 
              <valueQuantity>
                      <value value="2"/>
              </valueQuantity>
      </supportingInfo>

      <supportingInfo>
              <sequence value="3"/>
              <category>
                      <coding>
                              <code value="pharmacyinformation"/>
                      </coding>
              </category>
              <code>
                      <coding>
                              <system value="http://example.org/fhir/CodeSystem/pharmacy-information"/>
                              <code value="dayssupply"/>
                      </coding>
              </code> 
              <valueQuantity>
                      <value value="90"/>
              </valueQuantity>
      </supportingInfo>

      <diagnosis>
              <sequence value="1"/>
              <diagnosisCodeableConcept>
                      <coding>
                              <code value="654456"/>
                      </coding>
              </diagnosisCodeableConcept>
      </diagnosis>

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

      <item>
              <sequence value="1"/>
              <careTeamSequence value="1"/>
              <informationSequence value="1"/>
              <informationSequence value="2"/>
              <informationSequence value="3"/>
              <!--  type=packagemedication  -->
              <productOrService>
                      <coding>
                              <system value="http://www.nlm.nih.gov/research/umls/rxnorm"/>
                              <code value="562721"/> 
                              <display value="Alprazolam 0.25mg (Xanax)"/>
                      </coding> 
              </productOrService>
              <servicedDate value="2014-08-16"/>
              <quantity>
                      <value value="90"/>
                      <unit value="TAB"/>
                      <system value="http://unitsofmeasure.org"/> <!--  UCUM  -->
                      <code value="TAB"/>
              </quantity>
              <net>
                      <value value="90.00"/>
                      <currency value="USD"/> 
              </net> 
              <detail>
                      <sequence value="1"/>
                      <!--  type=costitem  -->
                      <productOrService>
                              <coding>
                                      <system value="http://hl7.org/fhir/ex-pharmaservice"/>
                                      <code value="drugcost"/> 
                              </coding> 
                      </productOrService>
                      <net>
                              <value value="45.00"/>
                              <currency value="USD"/> 
                      </net> 
              </detail>
              <detail>
                      <sequence value="2"/>
                      <!--  type=costitem  -->
                      <productOrService>
                              <coding>
                                      <system value="http://hl7.org/fhir/ex-pharmaservice"/>
                                      <code value="markup"/> 
                              </coding> 
                      </productOrService>
                      <net>
                              <value value="9.00"/>
                              <currency value="USD"/> 
                      </net> 
              </detail>
              <detail>
                      <sequence value="3"/>
                      <!--  type=costitem  -->
                      <productOrService>
                              <coding>
                                      <system value="http://hl7.org/fhir/ex-pharmaservice"/>
                                      <code value="dispensefee"/> 
                              </coding> 
                      </productOrService>
                      <net>
                              <value value="36.00"/>
                              <currency value="USD"/> 
                      </net> 
              </detail>
      </item>
      <total>
              <value value="90.00"/>
              <currency value="USD"/> 
      </total>

</Claim>