<?xml version=“1.0” encoding=“UTF-8”?><ClaimResponse xmlns=“hl7.org/fhir”>
<id value="R3500"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the ClaimResponse</div> </text> <identifier> <system value="http://www.BenefitsInc.com/fhir/remittance"/> <value value="R3500"/> </identifier> <request> <reference value="http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402"/> </request> <created value="2014-08-16"/> <organization> <reference value="Organization/2"/> </organization> <requestOrganization> <reference value="Organization/1"/> </requestOrganization> <outcome value="complete"/> <disposition value="Claim settled as per contract."/> <payeeType> <system value="http://hl7.org/fhir/payeetype"/> <code value="provider"/> </payeeType> <!-- Adjudication details --> <item> <sequenceLinkId value="1"/> <adjudication> <code> <code value="eligible"/> </code> <amount> <value value="135.57"/> <system value="urn:iso:std:iso:4217"/> <code value="USD"/> </amount> </adjudication> <adjudication> <code> <code value="copay"/> </code> <amount> <value value="10.00"/> <system value="urn:iso:std:iso:4217"/> <code value="USD"/> </amount> </adjudication> <adjudication> <code> <code value="eligpercent"/> </code> <value value="80.00"/> </adjudication> <adjudication> <code> <code value="benefit"/> </code> <amount> <value value="100.47"/> <system value="urn:iso:std:iso:4217"/> <code value="USD"/> </amount> </adjudication> </item> <totalCost> <value value="135.57"/> <system value="urn:iso:std:iso:4217"/> <code value="USD"/> </totalCost> <totalBenefit> <value value="100.47"/> <system value="urn:iso:std:iso:4217"/> <code value="USD"/> </totalBenefit> <!-- Payment details --> <paymentDate value="2014-08-31"/> <paymentAmount> <value value="100.47"/> <system value="urn:iso:std:iso:4217"/> <code value="USD"/> </paymentAmount> <paymentRef> <system value="http://www.BenefitsInc.com/fhir/paymentRef"/> <value value="201408-2-1569478"/> </paymentRef>
</ClaimResponse>