<?xml version="1.0" encoding="UTF-8"?><Claim xmlns="http://hl7.org/fhir">
  <id value="MED-00050"/>
  <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 a CMS 1500 Claim</div>
  </text>
  <contained>
    <Patient>
      <id value="patient-1"/>
      <name>
        <use value="official"/>
        <family value="Ashcraft"/>
        <given value="Alvina"/>
      </name>
      <gender value="female"/>
      <birthDate value="1954-06-11"/>
      <address>
        <use value="home"/>
        <line value="123 Main Street"/>
        <city value="Portland"/>
        <state value="OR"/>
        <postalCode value="97125"/>
        <country value="USA"/>
      </address>
    </Patient>
  </contained>
  <contained>
    <Coverage>
      <id value="coverage-1"/>
      <identifier>
        <system value="http://benefitsinc.com/certificate"/>
        <value value="10138556"/>
      </identifier>
      <status value="active"/>
      <kind value="insurance"/>
      <type>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
          <code value="HIP"/>
          <display value="health insurance plan policy"/>
        </coding>
      </type>
      <subscriber>
        <reference value="#patient-1"/>
      </subscriber>
      <beneficiary>
        <reference value="#patient-1"/>
      </beneficiary>
      <relationship>
        <coding>
          <code value="self"/>
        </coding>
      </relationship>
      <period>
        <start value="2015-01-01T00:00:00-07:00"/>
        <end value="2016-01-01T00:00:00-07:00"/>
      </period>
      <insurer>
        <identifier>
          <system value="http://www.bindb.com/bin"/>
          <value value="123456"/>
        </identifier>
        <display value="Humana Inc."/>
      </insurer>
      <class>
        <type>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/coverage-class"/>
            <code value="group"/>
          </coding>
        </type>
        <value>
          <value value="80902206"/>
        </value>
      </class>
    </Coverage>
  </contained>
  <identifier>
    <system value="http://CedarArmsMedicalCenter.com/claim"/>
    <value value="MED-00050"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="institutional"/>
    </coding>
  </type>
  <subType>
    <coding>
      <system value="https://www.cms.gov/codes/billtype"/>
      <code value="831"/>
      <display value="Hospital Outpatient Surgery performed in an Ambulatory ​Surgical Center"/>
    </coding>
  </subType>
  <use value="claim"/>
  <subject>
    <reference value="#patient-1"/>
  </subject>
  <created value="2015-10-16T00:00:00-07:00"/>
  <insurer>
    <identifier>
      <system value="http://www.bindb.com/bin"/>
      <value value="123456"/>
    </identifier>
    <display value="Humana Inc."/>
  </insurer>
  <provider>
    <reference value="Organization/1"/>
  </provider>
  <priority>
    <coding>
      <code value="normal"/>
    </coding>
  </priority>
  <payee>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
        <code value="provider"/>
      </coding>
    </type>
    <party>
      <reference value="Organization/1"/>
    </party>
  </payee>
  <careTeam>
    <sequence value="1"/>
    <provider>
      <reference value="Practitioner/example"/>
    </provider>
  </careTeam>
  <supportingInfo>
    <sequence value="1"/>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
        <code value="hospitalized"/>
      </coding>
    </category>
    <timingPeriod>
      <start value="2015-10-01T00:00:00-07:00"/>
      <end value="2015-10-05T00:00:00-07:00"/>
    </timingPeriod>
  </supportingInfo>
  <supportingInfo>
    <sequence value="2"/>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
        <code value="discharge"/>
      </coding>
    </category>
    <code>
      <coding>
        <system value="https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0801.pdf"/>
        <code value="01"/>
        <display value="Discharge to Home or Self Care"/>
      </coding>
    </code>
  </supportingInfo>
  <diagnosis>
    <sequence value="1"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/icd-10-cm"/>
        <code value="M96.1"/>
        <display value="Postlaminectomy syndrome, not elsewhere classified"/>
      </coding>
    </diagnosisCodeableConcept>
  </diagnosis>
  <diagnosis>
    <sequence value="2"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/icd-10-cm"/>
        <code value="G89.4"/>
        <display value="Chronic pain syndrome"/>
      </coding>
    </diagnosisCodeableConcept>
  </diagnosis>
  <diagnosis>
    <sequence value="3"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/icd-10-cm"/>
        <code value="M53.88"/>
        <display value="Other specified dorsopathies, sacral and sacrococcygeal region"/>
      </coding>
    </diagnosisCodeableConcept>
  </diagnosis>
  <diagnosis>
    <sequence value="4"/>
    <diagnosisCodeableConcept>
      <coding>
        <system value="http://hl7.org/fhir/sid/icd-10-cm"/>
        <code value="M47.816"/>
        <display value="Spondylosis without myelopathy or radiculopathy, lumbar region"/>
      </coding>
    </diagnosisCodeableConcept>
  </diagnosis>
  <insurance>
    <sequence value="1"/>
    <focal value="true"/>
    <identifier>
      <system value="http://CedarArmsMedicalCenter.com/claim"/>
      <value value="MED-00050"/>
    </identifier>
    <coverage>
      <reference value="#coverage-1"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <careTeamSequence value="1"/>
    <diagnosisSequence value="2"/>
    <diagnosisSequence value="4"/>
    <informationSequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://www.ama-assn.org/go/cpt"/>
        <code value="62264"/>
        <display value="Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day"/>
      </coding>
    </productOrService>
    <servicedDate value="2015-10-13"/>
    <locationCodeableConcept>
      <coding>
        <system value="https://www.cms.gov/medicare/coding/place-of-service-codes/place_of_service_code_set.html"/>
        <code value="24"/>
        <display value="Ambulatory Surgical Center"/>
      </coding>
    </locationCodeableConcept>
    <unitPrice>
      <value value="12500.00"/>
      <currency value="USD"/>
    </unitPrice>
    <net>
      <value value="12500.00"/>
      <currency value="USD"/>
    </net>
  </item>
  <total>
    <value value="12500.00"/>
    <currency value="USD"/>
  </total>
</Claim>