<?xml version="1.0" encoding="UTF-8"?><ClaimResponse xmlns="http://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>
  <text>
    <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml">A sample unsolicited pre-authorization response which authorizes basic dental services to be performed for a patient.</div>
  </text>
  <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  -->
  <subject>
    <reference value="Patient/1"/>
  </subject>
  <created value="2014-08-16"/>
  <insurer>
    <!--  Social Benefits Inc.  -->
    <identifier>
      <system value="http://www.jurisdiction.org/insurers"/>
      <value value="444123"/>
    </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>
      <quantity>
        <value value="100.00"/>
      </quantity>
    </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>
      <quantity>
        <value value="100.00"/>
      </quantity>
    </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>
      <coding>
        <system value="http://hl7.org/fhir/note-type"/>
        <code value="print"/>
      </coding>
    </type>
    <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>