<?xml version="1.0" encoding="UTF-8"?><Claim xmlns="http://hl7.org/fhir">
  <id value="660152"/>
  <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 Vision Claim for Glasses</div>
  </text>
  <!--  rest of the resource omitted for brevity  -->
  <contained>
    <Device>
      <id value="device-frame"/>
    </Device>
  </contained>
  <!--  rest of the resource omitted for brevity  -->
  <contained>
    <Device>
      <id value="device-lens"/>
    </Device>
  </contained>
  <identifier>
    <system value="http://happysight.com/claim"/>
    <value value="6612347"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="vision"/>
    </coding>
  </type>
  <use value="claim"/>
  <subject>
    <reference value="Patient/1"/>
  </subject>
  <created value="2014-08-16"/>
  <insurer>
    <reference value="Organization/2"/>
  </insurer>
  <provider>
    <reference value="Organization/1"/>
  </provider>
  <priority>
    <coding>
      <code value="normal"/>
    </coding>
  </priority>
  <prescription>
    <reference value="http://www.optdocs.com/prescription/12345"/>
  </prescription>
  <payee>
    <type>
      <coding>
        <code value="provider"/>
      </coding>
    </type>
  </payee>
  <careTeam>
    <sequence value="1"/>
    <provider>
      <reference value="Practitioner/example"/>
    </provider>
  </careTeam>
  <diagnosis>
    <sequence value="1"/>
    <diagnosisCodeableConcept>
      <coding>
        <code value="654321"/>
      </coding>
    </diagnosisCodeableConcept>
  </diagnosis>
  <insurance>
    <!--  Patient's own coverage - primary  -->
    <sequence value="1"/>
    <focal value="false"/>
    <coverage>
      <reference value="Coverage/9876B1"/>
    </coverage>
    <preAuthRef value="PR7652387237"/>
    <claimResponse>
      <reference value="ClaimResponse/R3500"/>
    </claimResponse>
  </insurance>
  <insurance>
    <!--  Spouses's own coverage - secondary  -->
    <sequence value="2"/>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/9876B1"/>
    </coverage>
    <preAuthRef value="AB543GTD7567"/>
  </insurance>
  <item>
    <sequence value="1"/>
    <careTeamSequence value="1"/>
    <revenue>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/>
        <code value="0010"/>
        <display value="Vision Clinic"/>
      </coding>
    </revenue>
    <category>
      <coding>
        <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/>
        <code value="F6"/>
        <display value="Vision Coverage"/>
      </coding>
    </category>
    <productOrService>
      <coding>
        <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
        <code value="glasses"/>
      </coding>
    </productOrService>
    <modifier>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/modifiers"/>
        <code value="rooh"/>
      </coding>
    </modifier>
    <programCode>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/ex-programcode"/>
        <code value="none"/>
      </coding>
    </programCode>
    <servicedDate value="2014-08-16"/>
    <unitPrice>
      <value value="235.40"/>
      <currency value="USD"/>
    </unitPrice>
    <net>
      <value value="235.40"/>
      <currency value="USD"/>
    </net>
    <detail>
      <sequence value="1"/>
      <revenue>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/>
          <code value="0010"/>
          <display value="Vision Clinic"/>
        </coding>
      </revenue>
      <category>
        <coding>
          <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/>
          <code value="F6"/>
          <display value="Vision Coverage"/>
        </coding>
      </category>
      <productOrService>
        <coding>
          <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
          <code value="frame"/>
        </coding>
      </productOrService>
      <modifier>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/modifiers"/>
          <code value="rooh"/>
        </coding>
      </modifier>
      <unitPrice>
        <value value="100.00"/>
        <currency value="USD"/>
      </unitPrice>
      <factor value="1.1"/>
      <!--  10% surcharge for out of hours work  -->
      <net>
        <value value="110.00"/>
        <currency value="USD"/>
      </net>
      <udi>
        <reference value="#device-frame"/>
      </udi>
    </detail>
    <detail>
      <sequence value="2"/>
      <revenue>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/>
          <code value="0010"/>
          <display value="Vision Clinic"/>
        </coding>
      </revenue>
      <category>
        <coding>
          <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/>
          <code value="F6"/>
          <display value="Vision Coverage"/>
        </coding>
      </category>
      <productOrService>
        <coding>
          <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
          <code value="lens"/>
        </coding>
      </productOrService>
      <programCode>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/ex-programcode"/>
          <code value="none"/>
        </coding>
      </programCode>
      <quantity>
        <value value="2"/>
      </quantity>
      <unitPrice>
        <value value="55.00"/>
        <currency value="USD"/>
      </unitPrice>
      <net>
        <value value="110.00"/>
        <currency value="USD"/>
      </net>
      <subDetail>
        <sequence value="1"/>
        <revenue>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/>
            <code value="0010"/>
            <display value="Vision Clinic"/>
          </coding>
        </revenue>
        <category>
          <coding>
            <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/>
            <code value="F6"/>
            <display value="Vision Coverage"/>
          </coding>
        </category>
        <productOrService>
          <coding>
            <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
            <code value="lens"/>
          </coding>
        </productOrService>
        <modifier>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/modifiers"/>
            <code value="rooh"/>
          </coding>
        </modifier>
        <programCode>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/ex-programcode"/>
            <code value="none"/>
          </coding>
        </programCode>
        <quantity>
          <value value="2"/>
        </quantity>
        <unitPrice>
          <value value="30.00"/>
          <currency value="USD"/>
        </unitPrice>
        <factor value="1.1"/>
        <!--  10% surchage for out of hours work  -->
        <net>
          <value value="66.00"/>
          <currency value="USD"/>
        </net>
        <udi>
          <reference value="#device-lens"/>
        </udi>
      </subDetail>
      <subDetail>
        <sequence value="2"/>
        <revenue>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/>
            <code value="0010"/>
            <display value="Vision Clinic"/>
          </coding>
        </revenue>
        <category>
          <coding>
            <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/>
            <code value="F6"/>
            <display value="Vision Coverage"/>
          </coding>
        </category>
        <productOrService>
          <coding>
            <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
            <code value="hardening"/>
          </coding>
        </productOrService>
        <modifier>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/modifiers"/>
            <code value="rooh"/>
          </coding>
        </modifier>
        <quantity>
          <value value="2"/>
        </quantity>
        <unitPrice>
          <value value="15.00"/>
          <currency value="USD"/>
        </unitPrice>
        <factor value="1.1"/>
        <!--  10% surchage for out of hours work  -->
        <net>
          <value value="33.00"/>
          <currency value="USD"/>
        </net>
      </subDetail>
      <subDetail>
        <sequence value="3"/>
        <revenue>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/>
            <code value="0010"/>
            <display value="Vision Clinic"/>
          </coding>
        </revenue>
        <category>
          <coding>
            <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/>
            <code value="F6"/>
            <display value="Vision Coverage"/>
          </coding>
        </category>
        <productOrService>
          <coding>
            <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
            <code value="UV coating"/>
          </coding>
        </productOrService>
        <modifier>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/modifiers"/>
            <code value="rooh"/>
          </coding>
        </modifier>
        <quantity>
          <value value="2"/>
        </quantity>
        <unitPrice>
          <value value="5.00"/>
          <currency value="USD"/>
        </unitPrice>
        <factor value="1.1"/>
        <!--  10% surchage for out of hours work  -->
        <net>
          <value value="11.00"/>
          <currency value="USD"/>
        </net>
      </subDetail>
    </detail>
    <detail>
      <sequence value="3"/>
      <revenue>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/ex-revenue-center"/>
          <code value="0010"/>
          <display value="Vision Clinic"/>
        </coding>
      </revenue>
      <category>
        <coding>
          <system value="http://example.org/fhir/CodeSystem/benefit-subcategory"/>
          <code value="F6"/>
          <display value="Vision Coverage"/>
        </coding>
      </category>
      <productOrService>
        <coding>
          <system value="http://example.org/fhir/CodeSystem/ex-visionservice"/>
          <code value="fst"/>
        </coding>
      </productOrService>
      <unitPrice>
        <value value="220.00"/>
        <currency value="USD"/>
      </unitPrice>
      <factor value="0.07"/>
      <net>
        <value value="15.40"/>
        <currency value="USD"/>
      </net>
    </detail>
  </item>
</Claim>