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

      <id value="R3502"/>

      <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://thebenefitcompany.com/claimresponse"/>
              <value value="CR6532875367"/>
      </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>

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

      <request>
              <identifier> 
                      <system value="http://happysight.com/claim"/>
                      <value value="6612346"/>
              </identifier>
      </request>

      <outcome value="complete"/>

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

      <payeeType>
              <coding>
                      <system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
                      <code value="provider"/>
              </coding>
      </payeeType>

      <!--  Adjudication details  -->

      <item>

              <itemSequence value="1"/> 

              <adjudication>
                      <category>
                              <coding>
                                      <code value="eligible"/>
                              </coding>
                      </category>
                      <amount>
                              <value value="235.40"/>
                              <currency value="USD"/>
                      </amount>
              </adjudication>

              <adjudication>
                      <category>
                              <coding>
                                      <code value="copay"/>
                              </coding>
                      </category>
                      <amount>
                              <value value="20.00"/>
                              <currency value="USD"/>
                      </amount>  
              </adjudication>

              <adjudication>
                      <category>
                              <coding>
                                      <code value="eligpercent"/>
                              </coding>
                      </category>
                      <value value="80.00"/>
              </adjudication>

              <adjudication>
                      <category>
                              <coding>
                                      <code value="benefit"/>
                              </coding>
                      </category>
                      <amount>
                              <value value="172.32"/>
                              <currency value="USD"/>
                      </amount>       
              </adjudication>

              <detail>
                      <detailSequence value="1"/> 
                      <noteNumber value="1"/>

                      <adjudication>
                              <category>
                                      <coding>
                                              <code value="eligible"/>
                                      </coding>
                              </category>
                              <amount>
                                      <value value="100.00"/>
                                      <currency value="USD"/>
                              </amount>
                      </adjudication>

                      <adjudication>
                              <category>
                                      <coding>
                                              <code value="copay"/>
                                      </coding>
                              </category>
                              <amount>
                                      <value value="20.00"/>
                                      <currency value="USD"/>
                              </amount>  
                      </adjudication>

                      <adjudication>
                              <category>
                                      <coding>
                                              <code value="eligpercent"/>
                                      </coding>
                              </category>
                              <value value="80.00"/>
                      </adjudication>

                      <adjudication>
                              <category>
                                      <coding>
                                              <code value="benefit"/>
                                      </coding>
                              </category>
                              <amount>
                                      <value value="80.00"/>
                                      <currency value="USD"/>
                              </amount>       
                      </adjudication>
              </detail>
              <detail>
                      <detailSequence value="2"/> 
                      <noteNumber value="1"/>

                      <adjudication>
                              <category>
                                      <coding>
                                              <code value="eligible"/>
                                      </coding>
                              </category>
                              <amount>
                                      <value value="110.00"/>
                                      <currency value="USD"/>
                              </amount>
                      </adjudication>

                      <adjudication>
                              <category>
                                      <coding>
                                              <code value="eligpercent"/>
                                      </coding>
                              </category>
                              <value value="80.00"/>
                      </adjudication>

                      <adjudication>
                              <category>
                                      <coding>
                                              <code value="benefit"/>
                                      </coding>
                              </category>
                              <amount>
                                      <value value="88.00"/>
                                      <currency value="USD"/>
                              </amount>       
                      </adjudication>

                      <subDetail>
                              <subDetailSequence value="1"/> 
                              <noteNumber value="1"/>

                              <adjudication>
                                      <category>
                                              <coding>
                                                      <code value="eligible"/>
                                              </coding>
                                      </category>
                                      <amount>
                                              <value value="60.00"/>
                                              <currency value="USD"/>
                                      </amount>
                              </adjudication>

                              <adjudication>
                                      <category>
                                              <coding>
                                                      <code value="eligpercent"/>
                                              </coding>
                                      </category>
                                      <value value="80.00"/>
                              </adjudication>

                              <adjudication>
                                      <category>
                                              <coding>
                                                      <code value="benefit"/>
                                              </coding>
                                      </category>
                                      <amount>
                                              <value value="48.00"/>
                                              <currency value="USD"/>
                                      </amount>       
                              </adjudication>

                      </subDetail>
                      <subDetail>
                              <subDetailSequence value="2"/> 

                              <adjudication>
                                      <category>
                                              <coding>
                                                      <code value="eligible"/>
                                              </coding>
                                      </category>
                                      <amount>
                                              <value value="30.00"/>
                                              <currency value="USD"/>
                                      </amount>
                              </adjudication>

                              <adjudication>
                                      <category>
                                              <coding>
                                                      <code value="eligpercent"/>
                                              </coding>
                                      </category>
                                      <value value="80.00"/>
                              </adjudication>

                              <adjudication>
                                      <category>
                                              <coding>
                                                      <code value="benefit"/>
                                              </coding>
                                      </category>
                                      <amount>
                                              <value value="24.00"/>
                                              <currency value="USD"/>
                                      </amount>       
                              </adjudication>

                      </subDetail>
                      <subDetail>
                              <subDetailSequence value="3"/> 
                              <noteNumber value="1"/>

                              <adjudication>
                                      <category>
                                              <coding>
                                                      <code value="eligible"/>
                                              </coding>
                                      </category>
                                      <amount>
                                              <value value="10.00"/>
                                              <currency value="USD"/>
                                      </amount>
                              </adjudication>

                              <adjudication>
                                      <category>
                                              <coding>
                                                      <code value="eligpercent"/>
                                              </coding>
                                      </category>
                                      <value value="80.00"/>
                              </adjudication>

                              <adjudication>
                                      <category>
                                              <coding>
                                                      <code value="benefit"/>
                                              </coding>
                                      </category>
                                      <amount>
                                              <value value="8.00"/>
                                              <currency value="USD"/>
                                      </amount>       
                              </adjudication>

                      </subDetail>
              </detail>
              <detail>
                      <detailSequence value="3"/> 
                      <noteNumber value="1"/>

                      <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="80.00"/>
                      </adjudication>

                      <adjudication>
                              <category>
                                      <coding>
                                              <code value="benefit"/>
                                      </coding>
                              </category>
                              <amount>
                                      <value value="14.00"/>
                                      <currency value="USD"/>
                              </amount>       
                      </adjudication>
              </detail>

      </item>

      <total>
              <category>
                      <coding>
                              <code value="submitted"/>
                      </coding>
              </category>
              <amount>
                      <value value="235.40"/>
                      <currency value="USD"/> 
              </amount> 
      </total>

      <total>
              <category>
                      <coding>
                              <code value="benefit"/>
                      </coding>
              </category>
              <amount>
                      <value value="182.00"/>
                      <currency value="USD"/> 
              </amount> 
      </total>

      <!--  Payment details  -->
      <payment>
              <type>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/ex-paymenttype"/>
                              <code value="complete"/>
                      </coding>
              </type> 

              <adjustment>
                      <value value="75.00"/>
                      <currency value="USD"/>
              </adjustment>

              <adjustmentReason>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/payment-adjustment-reason"/>
                              <code value="a002"/>
                              <display value="Prior Overpayment"/>
                      </coding>
              </adjustmentReason>

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

              <amount>
                      <value value="107.00"/>
                      <currency value="USD"/>
              </amount>       

              <identifier>
                      <system value="http://thebenefitcompany.com/paymentidentifier"/>
                      <value value="201416-123456"/>
              </identifier>   
      </payment>

      <processNote>
              <number value="1"/>
              <type value="display"/>
              <text value="After hours surcharge declined"/>
              <language>
                      <coding>
                              <system value="urn:ietf:bcp:47"/>
                              <code value="en-CA"/>
                      </coding>
              </language>
      </processNote>

</ClaimResponse>