<?xml version="1.0" encoding="UTF-8"?><ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="R3500"/>
  <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 human-readable rendering of the ClaimResponse</div>
  </text>
  <identifier>
    <system value="http://www.BenefitsInc.com/fhir/remittance"/>
    <value value="R3500"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="oral"/>
    </coding>
  </type>
  <subType>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/ex-claimsubtype"/>
      <code value="emergency"/>
    </coding>
  </subType>
  <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="Organization/1"/>
  </requestor>
  <request>
    <reference value="http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402"/>
  </request>
  <outcome value="complete"/>
  <disposition value="Claim settled as per contract."/>
  <payeeType>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
      <code value="provider"/>
    </coding>
  </payeeType>
  <!-- Adjudication details -->
  <item>
    <itemSequence value="1"/>
    <adjudication>
      <category>
        <coding>
          <code value="eligible"/>
        </coding>
      </category>
      <amount>
        <value value="135.57"/>
        <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="80.00"/>
      </quantity>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <code value="benefit"/>
        </coding>
      </category>
      <reason>
        <!-- should have paid 100.47 -->
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication-reason"/>
          <code value="ar002"/>
          <display value="Plan Limit Reached"/>
        </coding>
      </reason>
      <amount>
        <value value="90.47"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </item>
  <total>
    <category>
      <coding>
        <code value="submitted"/>
      </coding>
    </category>
    <amount>
      <value value="135.57"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <code value="benefit"/>
      </coding>
    </category>
    <amount>
      <value value="90.47"/>
      <currency value="USD"/>
    </amount>
  </total>
  <!-- Payment details -->
  <payment>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/ex-paymenttype"/>
        <code value="complete"/>
      </coding>
    </type>
    <date value="2014-08-31"/>
    <amount>
      <value value="100.47"/>
      <currency value="USD"/>
    </amount>
    <identifier>
      <system value="http://www.BenefitsInc.com/fhir/paymentidentifier"/>
      <value value="201408-2-1569478"/>
    </identifier>
  </payment>
</ClaimResponse>