<?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>