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

      <id value="660152"/>

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

      <contained>
              <Device>
                      <id value="device-frame"/>
                      <!--  rest of the resource omitted for brevity  -->
              </Device>
      </contained>

      <contained>
              <Device>
                      <id value="device-lens"/>
                      <!--  rest of the resource omitted for brevity  -->
              </Device>
      </contained>

      <identifier>
              <system value="http://happysight.com/claim"/>
              <value value="6612347"/>
      </identifier>

      <status value="active"/>

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

      <prescription>
              <reference value="http://www.optdocs.com/VisionPrescription/12345"/>
      </prescription>   

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

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

      <diagnosis>
              <sequence value="1"/>
              <diagnosisCodeableConcept>
                      <coding>
                              <code value="654321"/>
                      </coding>
              </diagnosisCodeableConcept>
      </diagnosis>

      <insurance> <!--  Patient's own coverage - primary  -->
              <sequence value="1"/>
              <focal value="false"/>
              <coverage>
                      <reference value="Coverage/9876B1"/>
              </coverage>
              <preAuthRef value="PR7652387237"/>
              <claimResponse>
                      <reference value="ClaimResponse/R3500"/>
              </claimResponse>
      </insurance>

      <insurance> <!--  Spouses's own coverage - secondary  -->
              <sequence value="2"/>
              <focal value="true"/>
              <coverage>
                      <reference value="Coverage/9876B1"/>
              </coverage>
              <preAuthRef value="AB543GTD7567"/>
      </insurance>

      <item>
              <sequence value="1"/>
              <careTeamSequence value="1"/>
              <revenue>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/>
                              <code value="0010"/>
                              <display value="Vision Clinic"/>
                      </coding>
              </revenue>
              <category>
                      <coding>
                              <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/>
                              <code value="F6"/>
                              <display value="Vision Coverage"/>
                      </coding>
              </category>
              <productOrService>
                      <coding>
                              <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
                              <code value="glasses"/>
                      </coding>
              </productOrService>
              <modifier>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/modifiers"/>
                              <code value="rooh"/>
                      </coding>
              </modifier>
              <programCode>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/ex-programcode"/>
                              <code value="none"/>
                      </coding>
              </programCode>  
              <servicedDate value="2014-08-16"/>
              <unitPrice>
                      <value value="235.40"/>
                      <currency value="USD"/> 
              </unitPrice> 
              <net>
                      <value value="235.40"/>
                      <currency value="USD"/> 
              </net> 

              <detail>
                      <sequence value="1"/>
                      <revenue>
                              <coding>
                                      <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/>
                                      <code value="0010"/>
                                      <display value="Vision Clinic"/>
                              </coding>
                      </revenue>
                      <category>
                              <coding>
                                      <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/>
                                      <code value="F6"/>
                                      <display value="Vision Coverage"/>
                              </coding>
                      </category>
                      <productOrService>
                              <coding>
                                      <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
                                      <code value="frame"/>
                              </coding>
                      </productOrService>
                      <modifier>
                              <coding>
                                      <system value="http://terminology.hl7.org/CodeSystem/modifiers"/>
                                      <code value="rooh"/>
                              </coding>
                      </modifier>
                      <unitPrice>
                              <value value="100.00"/>
                              <currency value="USD"/> 
                      </unitPrice> 
                      <factor value="1.1"/> <!--  10% surcharge for out of hours work  -->
                      <net>
                              <value value="110.00"/>
                              <currency value="USD"/> 
                      </net> 
                      <udi>
                              <reference value="#device-frame"/>
                      </udi>
              </detail>

              <detail>
                      <sequence value="2"/>
                      <revenue>
                              <coding>
                                      <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/>
                                      <code value="0010"/>
                                      <display value="Vision Clinic"/>
                              </coding>
                      </revenue>
                      <category>
                              <coding>
                                      <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/>
                                      <code value="F6"/>
                                      <display value="Vision Coverage"/>
                              </coding>
                      </category>
                      <productOrService>
                              <coding>
                                      <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
                                      <code value="lens"/>
                              </coding>
                      </productOrService>
                      <programCode>
                              <coding>
                                      <system value="http://terminology.hl7.org/CodeSystem/ex-programcode"/>
                                      <code value="none"/>
                              </coding>
                      </programCode>  
                      <quantity>
                              <value value="2"/>
                      </quantity>
                      <unitPrice>
                              <value value="55.00"/>
                              <currency value="USD"/> 
                      </unitPrice> 
                      <net>
                              <value value="110.00"/>
                              <currency value="USD"/> 
                      </net> 

                      <subDetail>
                              <sequence value="1"/>
                              <revenue>
                                      <coding>
                                              <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/>
                                              <code value="0010"/>
                                              <display value="Vision Clinic"/>
                                      </coding>
                              </revenue>
                              <category>
                                      <coding>
                                              <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/>
                                              <code value="F6"/>
                                              <display value="Vision Coverage"/>
                                      </coding>
                              </category>
                              <productOrService>
                                      <coding>
                                              <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
                                              <code value="lens"/>
                                      </coding>
                              </productOrService>
                              <modifier>
                                      <coding>
                                              <system value="http://terminology.hl7.org/CodeSystem/modifiers"/>
                                              <code value="rooh"/>
                                      </coding>
                              </modifier>
                              <programCode>
                                      <coding>
                                              <system value="http://terminology.hl7.org/CodeSystem/ex-programcode"/>
                                              <code value="none"/>
                                      </coding>
                              </programCode>  
                              <quantity>
                                      <value value="2"/>
                              </quantity>
                              <unitPrice>
                                      <value value="30.00"/>
                                      <currency value="USD"/> 
                              </unitPrice> 
                              <factor value="1.1"/> <!--  10% surchage for out of hours work  -->
                              <net>
                                      <value value="66.00"/>
                                      <currency value="USD"/> 
                              </net> 
                              <udi>
                                      <reference value="#device-lens"/>
                              </udi>
                      </subDetail>

                      <subDetail>
                              <sequence value="2"/>
                              <revenue>
                                      <coding>
                                              <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/>
                                              <code value="0010"/>
                                              <display value="Vision Clinic"/>
                                      </coding>
                              </revenue>
                              <category>
                                      <coding>
                                              <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/>
                                              <code value="F6"/>
                                              <display value="Vision Coverage"/>
                                      </coding>
                              </category>
                              <productOrService>
                                      <coding>
                                              <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
                                              <code value="hardening"/>
                                      </coding>
                              </productOrService>
                              <modifier>
                                      <coding>
                                              <system value="http://terminology.hl7.org/CodeSystem/modifiers"/>
                                              <code value="rooh"/>
                                      </coding>
                              </modifier>
                              <quantity>
                                      <value value="2"/>
                              </quantity>
                              <unitPrice>
                                      <value value="15.00"/>
                                      <currency value="USD"/> 
                              </unitPrice> 
                              <factor value="1.1"/> <!--  10% surchage for out of hours work  -->
                              <net>
                                      <value value="33.00"/>
                                      <currency value="USD"/> 
                              </net> 
                      </subDetail>

                      <subDetail>
                              <sequence value="3"/>
                              <revenue>
                                      <coding>
                                              <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/>
                                              <code value="0010"/>
                                              <display value="Vision Clinic"/>
                                      </coding>
                              </revenue>
                              <category>
                                      <coding>
                                              <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/>
                                              <code value="F6"/>
                                              <display value="Vision Coverage"/>
                                      </coding>
                              </category>
                              <productOrService>
                                      <coding>
                                              <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
                                              <code value="UV coating"/>
                                      </coding>
                              </productOrService>
                              <modifier>
                                      <coding>
                                              <system value="http://terminology.hl7.org/CodeSystem/modifiers"/>
                                              <code value="rooh"/>
                                      </coding>
                              </modifier>
                              <quantity>
                                      <value value="2"/>
                              </quantity>
                              <unitPrice>
                                      <value value="5.00"/>
                                      <currency value="USD"/> 
                              </unitPrice> 
                              <factor value="1.1"/> <!--  10% surchage for out of hours work  -->
                              <net>
                                      <value value="11.00"/>
                                      <currency value="USD"/> 
                              </net> 
                      </subDetail>
              </detail>

              <detail>
                      <sequence value="3"/>
                      <revenue>
                              <coding>
                                      <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/>
                                      <code value="0010"/>
                                      <display value="Vision Clinic"/>
                              </coding>
                      </revenue>
                      <category>
                              <coding>
                                      <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/>
                                      <code value="F6"/>
                                      <display value="Vision Coverage"/>
                              </coding>
                      </category>
                      <productOrService>
                              <coding>
                                      <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
                                      <code value="fst"/>
                              </coding>
                      </productOrService>
                      <unitPrice>
                              <value value="220.00"/>
                              <currency value="USD"/> 
                      </unitPrice> 
                      <factor value="0.07"/>
                      <net>
                              <value value="15.40"/>
                              <currency value="USD"/> 
                      </net> 
              </detail>
      </item>

</Claim>