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

      <id value="100151"/>

      <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="12346"/>
      </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>
              <reference value="Organization/2"/>
      </insurer>

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

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

      <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>
                              <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
                              <code value="missingtooth"/>
                      </coding>
              </category>
              <code>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/ex-tooth"/>
                              <code value="15"/>
                      </coding>
              </code>
              <timingDate value="2012-04-07"/>
              <reason>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/missingtoothreason"/>
                              <code value="e"/>       <!--  Extraction  -->
                      </coding>
              </reason>
      </supportingInfo>

      <supportingInfo>
              <sequence value="2"/>
              <category>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
                              <code value="exception"/>
                      </coding>
              </category>
              <code>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/claim-exception"/>
                              <code value="student"/>
                      </coding>
              </code>
              <valueString value="Happy Valley Community College"/>
      </supportingInfo>

      <diagnosis>
              <sequence value="1"/>
              <diagnosisCodeableConcept>
                      <coding>
                              <code value="123456"/>
                      </coding>
              </diagnosisCodeableConcept>
      </diagnosis>

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

      <item>
              <sequence value="1"/>
              <careTeamSequence value="1"/>
              <productOrService>
                      <coding>
                              <system value="http://example.org/fhir/oralservicecodes"/>
                              <code value="1200"/>
                      </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> 
      </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="1000.00"/>
                              <currency value="USD"/> 
                      </unitPrice> 
                      <factor value="0.75"/>  <!--  Student discount  -->
                      <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>