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

      <id value="EB3501"/>

      <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://www.BenefitsInc.com/fhir/explanationofbenefit"/>
              <value value="error-1"/>
      </identifier>

      <status value="active"/>

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

      <subType>
              <coding>
                      <system value="http://terminology.hl7.org/CodeSystem/ex-claimsubtype"/>
                      <code value="emergency"/>
              </coding>
      </subType>

      <use value="claim"/>

      <patient>
              <reference value="Patient/pat1"/>
      </patient>

      <billablePeriod>
              <start value="2014-02-01"/>
              <end value="2014-03-01"/>
      </billablePeriod>

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

      <enterer>
              <reference value="Practitioner/1"/>
      </enterer>

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

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

      <related>
              <reference>
                      <system value="http://www.BenefitsInc.com/case-number"/>
                      <value value="23-56Tu-XX-47-20150M14"/>
              </reference>
      </related>

      <prescription>
              <reference value="MedicationRequest/medrx002"/>
      </prescription>

      <originalPrescription>
              <reference value="MedicationRequest/medrx0301"/>
      </originalPrescription>

      <facility>
              <reference value="Location/1"/>
      </facility>

      <claim>
              <reference value="Claim/100150"/>
      </claim>

      <claimResponse>
              <reference value="ClaimResponse/R3500"/>
      </claimResponse> 

      <outcome value="error"/>

      <disposition value="Could not process."/>

      <supportingInfo>
              <sequence value="1"/>
              <category>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
                              <code value="employmentimpacted"/>
                      </coding>
              </category>
              <timingPeriod>
                      <start value="2014-02-14"/>
                      <end value="2014-02-28"/>
              </timingPeriod>
      </supportingInfo>

      <supportingInfo>
              <sequence value="2"/>
              <category>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
                              <code value="hospitalized"/>
                      </coding>
              </category>
              <timingPeriod>
                      <start value="2014-02-14"/>
                      <end value="2014-02-16"/>
              </timingPeriod>
      </supportingInfo>

      <procedure>
              <sequence value="1"/>
              <date value="2014-02-14"/>
              <procedureCodeableConcept>
                      <coding>
                              <system value="http://hl7.org/fhir/sid/ex-icd-10-procedures"/>
                              <code value="123001"/>
                      </coding>
              </procedureCodeableConcept>
              <udi>
                      <reference value="Device/example"/>
              </udi>
      </procedure>

      <precedence value="2"/>

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

      <accident>
              <date value="2014-02-14"/>
              <type>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
                              <code value="SPT"/>
                      </coding>
              </type>
              <locationReference>
                      <reference value="Location/ph"/>
              </locationReference>
      </accident>

      <total>
              <category>
                      <coding>
                              <code value="submitted"/>
                      </coding>
              </category>
              <amount>
                      <value value="2478.57"/>
                      <currency value="USD"/> 
              </amount> 
      </total>

      <total>
              <category>
                      <coding>
                              <code value="benefit"/>
                      </coding>
              </category>
              <amount>
                      <value value="0.00"/>
                      <currency value="USD"/> 
              </amount> 
      </total>

      <formCode>
              <coding>
                      <system value="http://terminology.hl7.org/CodeSystem/forms-codes"/>
                      <code value="2"/>
              </coding>
      </formCode>

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

</ExplanationOfBenefit>