<?xml version="1.0" encoding="UTF-8"?>

<CoverageEligibilityResponse xmlns="http://hl7.org/fhir">
  <id value="E2503"/>
  <text>
    <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the CoverageEligibilityResponse.</div>
  </text>
  <identifier>
    <system value="http://www.BenefitsInc.com/fhir/coverageeligibilityresponse"/>
    <value value="8812343"/>
  </identifier>
  <status value="active"/>
  <purpose value="validation"/>
  <patient>
    <reference value="Patient/f201"/>
  </patient>
  <created value="2014-09-16"/>
  <requestor>
    <identifier>
      <system value="http://national.org/clinic"/>
      <value value="OR1234"/>
    </identifier>
  </requestor>
  <request>
    <reference value="http://www.BenefitsInc.com/fhir/coverageeligibilityresponse/225476332406"/>
  </request>
  <outcome value="error"/>
  <disposition value="Eligibiliy request could not be processed, please address errors before submitting."/>
  <insurer>
    <reference value="Organization/2"/>
  </insurer>
  <form>
    <coding>
      <system value="http://national.org/form"/>
      <code value="ELRSP/2017/01"/>
    </coding>
  </form>
  <error>
    <code>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication-error"/>
        <code value="a001"/>
      </coding>
    </code>
  </error>
</CoverageEligibilityResponse>