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

      <id value="UR3503"/>

      <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.SocialBenefitsInc.com/fhir/ClaimResponse"/>
              <value value="UR3503"/>
      </identifier>

      <status value="active"/>

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

      <use value="preauthorization"/> <!--  this is unsolicited therefore no reference to the preauthorization request exists  -->

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

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

      <insurer>
              <identifier>
                      <system value="http://www.jurisdiction.org/insurers"/>
                      <value value="444123"/> <!--  Social Benefits Inc.  -->
              </identifier>
      </insurer>

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

      <outcome value="complete"/>

      <disposition value="The enclosed services are authorized for your provision within 30 days of this notice."/>

      <preAuthRef value="18SS12345"/>

      <payeeType>     <!--  advise that assignment of benefit is allowed  -->
              <coding>
                      <system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
                      <code value="provider"/>
              </coding>
      </payeeType>

      <!--  Authorization details  -->

      <!--  Authorization to receive an exam and an Xray panel  -->
      <addItem> <!--  Exam  -->
              <itemSequence value="1"/> 
              <productOrService>
                      <coding>
                              <system value="http://example.org/fhir/oralservicecodes"/>
                              <code value="1101"/>
                      </coding>
              </productOrService>
              <modifier>
                      <coding>
                              <system value="http://example.org/fhir/modifiers"/>
                              <code value="x"/>
                              <display value="None"/>
                      </coding>
              </modifier>
              <net>
                      <value value="250.00"/> <!--  net set to same value as the eligible amount. Providers will only be reimbursed to the net/eligible amount less the co-pay.  -->
                      <currency value="USD"/>
              </net>
              <noteNumber value="101"/>
              <adjudication>
                      <category>
                              <coding>
                                      <code value="eligible"/>
                              </coding>
                      </category>
                      <amount>
                              <value value="250.00"/>
                              <currency value="USD"/>
                      </amount>
              </adjudication>

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

              <adjudication>
                      <category>
                              <coding>
                                      <code value="eligpercent"/>
                              </coding>
                      </category>
                      <value value="100.00"/>
              </adjudication>
              <adjudication>
                      <category>
                              <coding>
                                      <code value="benefit"/>
                              </coding>
                      </category>
                      <amount>
                              <value value="240.00"/> <!--  insurer will pay up to this amount.  -->
                              <currency value="USD"/>
                      </amount>       
              </adjudication>

      </addItem>

      <addItem> <!--  Xray Panel  -->
              <itemSequence value="1"/> 
              <productOrService>
                      <coding>
                              <system value="http://example.org/fhir/oralservicecodes"/>
                              <code value="2101"/>
                              <display value="Radiograph, series (12)"/>
                      </coding>
              </productOrService>
              <net>
                      <value value="800.00"/>
                      <currency value="USD"/>
              </net>
              <adjudication>
                      <category>
                              <coding>
                                      <code value="eligible"/>
                              </coding>
                      </category>
                      <amount>
                              <value value="800.00"/>
                              <currency value="USD"/>
                      </amount>
              </adjudication>

              <adjudication>
                      <category>
                              <coding>
                                      <code value="eligpercent"/>
                              </coding>
                      </category>
                      <value value="100.00"/>
              </adjudication>
              <adjudication>
                      <category>
                              <coding>
                                      <code value="benefit"/>
                              </coding>
                      </category>
                      <amount>
                              <value value="800.00"/>
                              <currency value="USD"/>
                      </amount>       
              </adjudication>
      </addItem>

      <total>
              <category>
                      <coding>
                              <code value="submitted"/>
                      </coding>
              </category>
              <amount>
                      <value value="1050.00"/>
                      <currency value="USD"/> 
              </amount> 
      </total>

      <total>
              <category>
                      <coding>
                              <code value="benefit"/>
                      </coding>
              </category>
              <amount>
                      <value value="1040.00"/>
                      <currency value="USD"/> 
              </amount> 
      </total>

      <processNote>
              <number value="101"/>
              <type value="print"/>
              <text value="Please submit a Pre-Authorization request if a more extensive examination or urgent services are required."/>
              <language>
                      <coding>
                              <system value="urn:ietf:bcp:47"/>
                              <code value="en-CA"/>
                      </coding>
              </language>
      </processNote>  

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

</ClaimResponse>