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

      <id value="100153"/>

      <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://happyvalley.com/claim"/>
              <value value="12355"/>
      </identifier>

      <status value="active"/>

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

      <use value="preauthorization"/>

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

      <created value="2015-03-16"/>

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

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

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

      <fundsReserve>
              <coding>
                      <code value="provider"/>
              </coding>
      </fundsReserve>

      <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>
                              <system value="http://hl7.org/fhir/sid/icd-10"/>
                              <code value="123457"/>
                      </coding>
              </diagnosisCodeableConcept>
      </diagnosis>

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

      <item>
              <sequence value="1"/>
              <careTeamSequence value="1"/>
              <diagnosisSequence value="1"/>
              <productOrService>
                      <coding>
                              <system value="http://example.org/fhir/oralservicecodes"/>
                              <code value="ORTHPLAN"/>
                      </coding>
              </productOrService>
              <servicedDate value="2015-05-16"/>  <!--  Start Date  -->
              <unitPrice>
                      <value value="9000.00"/>
                      <currency value="USD"/> 
              </unitPrice> 
              <net>
                      <value value="9000.00"/>
                      <currency value="USD"/> 
              </net> 
              <detail>
                      <sequence value="1"/> <!--  Exam Fee  -->
                      <productOrService>
                              <coding>
                                      <system value="http://example.org/fhir/oralservicecodes"/>
                                      <code value="ORTHOEXAM"/>
                              </coding>
                      </productOrService>
                      <unitPrice>
                              <value value="1000.00"/>
                              <currency value="USD"/> 
                      </unitPrice> 
                      <net>
                              <value value="1000.00"/>
                              <currency value="USD"/> 
                      </net> 
              </detail>
              <detail>
                      <sequence value="2"/> <!--  Diagnostic Fee  -->
                      <productOrService>
                              <coding>
                                      <system value="http://example.org/fhir/oralservicecodes"/>
                                      <code value="ORTHODIAG"/>
                              </coding>
                      </productOrService>
                      <unitPrice>
                              <value value="1500.00"/>
                              <currency value="USD"/> 
                      </unitPrice> 
                      <net>
                              <value value="1500.00"/>
                              <currency value="USD"/> 
                      </net> 
              </detail>
              <detail>
                      <sequence value="3"/> <!--  Initial Payment  -->
                      <productOrService>
                              <coding>
                                      <system value="http://example.org/fhir/oralservicecodes"/>
                                      <code value="ORTHOINITIAL"/>
                              </coding>
                      </productOrService>
                      <unitPrice>
                              <value value="500.00"/>
                              <currency value="USD"/> 
                      </unitPrice> 
                      <net>
                              <value value="500.00"/>
                              <currency value="USD"/> 
                      </net> 
              </detail>
              <detail>
                      <sequence value="4"/> <!--  Duration in Months  -->
                      <productOrService>
                              <coding>
                                      <system value="http://example.org/fhir/oralservicecodes"/>
                                      <code value="ORTHOMONTHS"/>
                              </coding>
                      </productOrService>
                      <quantity>
                              <value value="24"/>
                      </quantity>  
              </detail>
              <detail>
                      <sequence value="5"/> <!--  Periodic Payments  -->
                      <productOrService>
                              <coding>
                                      <system value="http://example.org/fhir/oralservicecodes"/>
                                      <code value="ORTHOPERIODIC"/>
                              </coding>
                      </productOrService>
                      <quantity>
                              <value value="24"/>
                      </quantity>  
                      <unitPrice>
                              <value value="250.00"/>
                              <currency value="USD"/> 
                      </unitPrice> 
                      <net>
                              <value value="250.00"/>
                              <currency value="USD"/> 
                      </net> 
              </detail>
      </item>

      <item>
              <sequence value="2"/>
              <careTeamSequence value="1"/>
              <productOrService>
                      <coding>
                              <system value="http://example.org/fhir/oralservicecodes"/>
                              <code value="21211"/>
                      </coding>
              </productOrService>
              <servicedDate value="2014-08-16"/>
              <unitPrice>
                      <value value="105.00"/>
                      <currency value="USD"/> 
              </unitPrice> 
              <net>
                      <value value="105.00"/>
                      <currency value="USD"/> 
              </net> 
              <bodySite>
                      <coding>
                              <system value="http://fdi.org/fhir/oraltoothcodes"/>
                              <code value="21"/>
                      </coding>
              </bodySite>
              <subSite>
                      <coding>
                              <system value="http://fdi.org/fhir/oralsurfacecodes"/>
                              <code value="L"/>
                      </coding>
              </subSite>
      </item>

      <item>
              <sequence value="3"/>
              <careTeamSequence value="1"/>
              <productOrService>
                      <coding>
                              <system value="http://example.org/fhir/oralservicecodes"/>
                              <code value="27211"/>
                      </coding>
              </productOrService>
              <servicedDate value="2014-08-16"/>
              <unitPrice>
                      <value value="1100.00"/>
                      <currency value="USD"/> 
              </unitPrice> 
              <net>
                      <value value="1100.00"/>
                      <currency value="USD"/> 
              </net> 
              <bodySite>
                      <coding>
                              <system value="http://fdi.org/fhir/oraltoothcodes"/>
                              <code value="36"/>
                      </coding>
              </bodySite>
              <detail>
                      <sequence value="1"/>
                      <productOrService>
                              <coding>
                                      <system value="http://example.org/fhir/oralservicecodes"/>
                                      <code value="27211"/>
                              </coding>
                      </productOrService>
                      <unitPrice>
                              <value value="750.00"/>
                              <currency value="USD"/> 
                      </unitPrice> 
                      <net>
                              <value value="750.00"/>
                              <currency value="USD"/> 
                      </net> 
              </detail>
              <detail>
                      <sequence value="2"/>
                      <productOrService>
                              <coding>
                                      <system value="http://example.org/fhir/oralservicecodes"/>
                                      <code value="lab"/>
                              </coding>
                      </productOrService>
                      <unitPrice>
                              <value value="350.00"/>
                              <currency value="USD"/> 
                      </unitPrice> 
                      <net>
                              <value value="350.00"/>
                              <currency value="USD"/> 
                      </net> 
              </detail>
      </item>

</Claim>