<?xml version="1.0" encoding="UTF-8"?><ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="R3503"/>
  <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 to Claim Oral Average with additional items</div>
  </text>
  <identifier>
    <system value="http://www.BenefitsInc.com/fhir/remittance"/>
    <value value="R3503"/>
  </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="Organization/1"/>
  </requestor>
  <request>
    <identifier>
      <system value="http://happyvalley.com/claim"/>
      <value value="12346"/>
    </identifier>
  </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>
    <!--  Pays for a claim package code with two actual codes with adjudication details  -->
    <itemSequence value="1"/>
    <adjudication>
      <category>
        <coding>
          <code value="eligible"/>
        </coding>
      </category>
      <amount>
        <value value="0.00"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <code value="benefit"/>
        </coding>
      </category>
      <amount>
        <value value="0.00"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </item>
  <item>
    <itemSequence value="2"/>
    <adjudication>
      <category>
        <coding>
          <code value="eligible"/>
        </coding>
      </category>
      <amount>
        <value value="105.00"/>
        <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>
      <amount>
        <value value="84.00"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </item>
  <item>
    <itemSequence value="3"/>
    <adjudication>
      <category>
        <coding>
          <code value="eligible"/>
        </coding>
      </category>
      <amount>
        <value value="750.00"/>
        <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>
      <amount>
        <value value="600.00"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <detail>
      <detailSequence value="1"/>
      <adjudication>
        <category>
          <coding>
            <code value="eligible"/>
          </coding>
        </category>
        <amount>
          <value value="750.00"/>
          <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>
        <amount>
          <value value="600.00"/>
          <currency value="USD"/>
        </amount>
      </adjudication>
    </detail>
    <detail>
      <!--  See the addItem.detail below  -->
      <detailSequence value="2"/>
      <adjudication>
        <category>
          <coding>
            <code value="eligible"/>
          </coding>
        </category>
        <amount>
          <value value="0.00"/>
          <currency value="USD"/>
        </amount>
      </adjudication>
      <adjudication>
        <category>
          <coding>
            <code value="benefit"/>
          </coding>
        </category>
        <amount>
          <value value="0.00"/>
          <currency value="USD"/>
        </amount>
      </adjudication>
    </detail>
  </item>
  <!--  Pays for a claim package code (1200) with two actual codes (1101, 2141) with adjudication details  -->
  <addItem>
    <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="135.57"/>
      <currency value="USD"/>
    </net>
    <noteNumber value="101"/>
    <adjudication>
      <category>
        <coding>
          <code value="eligible"/>
        </coding>
      </category>
      <amount>
        <value value="100.00"/>
        <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="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="72.00"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </addItem>
  <addItem>
    <itemSequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://example.org/fhir/oralservicecodes"/>
        <code value="2141"/>
        <display value="Radiograph, bytewing"/>
      </coding>
    </productOrService>
    <net>
      <value value="35.57"/>
      <currency value="USD"/>
    </net>
    <adjudication>
      <category>
        <coding>
          <code value="eligible"/>
        </coding>
      </category>
      <amount>
        <value value="35.57"/>
        <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>
      <amount>
        <value value="28.47"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </addItem>
  <!--  Pays for a claim package code (1200) with two actual codes (1101, 2141) with adjudication details  -->
  <addItem>
    <itemSequence value="3"/>
    <detailSequence value="2"/>
    <productOrService>
      <coding>
        <system value="http://example.org/fhir/oralservicecodes"/>
        <code value="expense"/>
      </coding>
    </productOrService>
    <modifier>
      <coding>
        <system value="http://example.org/fhir/modifiers"/>
        <code value="x"/>
        <display value="None"/>
      </coding>
    </modifier>
    <net>
      <value value="350.00"/>
      <currency value="USD"/>
    </net>
    <noteNumber value="101"/>
    <adjudication>
      <category>
        <coding>
          <code value="eligible"/>
        </coding>
      </category>
      <amount>
        <value value="350.00"/>
        <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>
      <amount>
        <value value="270.00"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </addItem>
  <total>
    <category>
      <coding>
        <code value="submitted"/>
      </coding>
    </category>
    <amount>
      <value value="1340.57"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <code value="benefit"/>
      </coding>
    </category>
    <amount>
      <value value="1054.47"/>
      <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="201408-2-15507"/>
    </identifier>
  </payment>
  <processNote>
    <number value="101"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/note-type"/>
        <code value="print"/>
      </coding>
    </type>
    <text value="Package codes are not permitted. Codes replaced by Insurer."/>
    <language>
      <coding>
        <system value="urn:ietf:bcp:47"/>
        <code value="en-CA"/>
      </coding>
    </language>
  </processNote>
</ClaimResponse>