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

<ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="R3501"/>
  <text>
    <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the ClaimResponse that demonstrates returning errors</div>
  </text>
  <identifier>
    <system value="http://www.BenefitsInc.com/fhir/remittance"/>
    <value value="R3501"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="oral"/>
    </coding>
  </type>
  <use value="claim"/>
  <subject>
    <reference value="Patient/1"/>
  </subject>
  <created value="2014-08-16"/>
  <insurer>
    <identifier>
      <system value="http://www.jurisdiction.org/insurers"/>
      <value value="555123"/>
    </identifier>
  </insurer>
  <requestor>
    <reference value="Practitioner/1"/>
  </requestor>
  <request>
    <reference value="Claim/100156"/>
  </request>
  <outcome value="error"/>
  <disposition value="Claim could not be processed"/>
  <formCode>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/forms-codes"/>
      <code value="2"/>
    </coding>
  </formCode>
  <processNote>
    <number value="1"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/note-type"/>
        <code value="display"/>
      </coding>
    </type>
    <text value="Invalid claim"/>
    <language>
      <coding>
        <system value="urn:ietf:bcp:47"/>
        <code value="en-CA"/>
      </coding>
    </language>
  </processNote>
  <communicationRequest>
    <reference value="CommunicationRequest/fm-solicit"/>
  </communicationRequest>
  <!--  Detailed error description  -->
  <error>
    <itemSequence value="3"/>
    <detailSequence value="2"/>
    <code>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/adjudication-error"/>
        <code value="a002"/>
      </coding>
    </code>
  </error>
</ClaimResponse>