<?xml version="1.0" encoding="UTF-8"?><ClaimResponse xmlns="http://hl7.org/fhir">
  <id value="R3502"/>
  <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://thebenefitcompany.com/claimresponse"/>
    <value value="CR6532875367"/>
  </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>
  <requestor>
    <reference value="Organization/1"/>
  </requestor>
  <request>
    <identifier>
      <system value="http://happysight.com/claim"/>
      <value value="6612346"/>
    </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>
    <itemSequence value="1"/>
    <adjudication>
      <category>
        <coding>
          <code value="eligible"/>
        </coding>
      </category>
      <amount>
        <value value="235.40"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <code value="copay"/>
        </coding>
      </category>
      <amount>
        <value value="20.00"/>
        <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="172.32"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <detail>
      <detailSequence value="1"/>
      <noteNumber value="1"/>
      <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="20.00"/>
          <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="80.00"/>
          <currency value="USD"/>
        </amount>
      </adjudication>
    </detail>
    <detail>
      <detailSequence value="2"/>
      <noteNumber value="1"/>
      <adjudication>
        <category>
          <coding>
            <code value="eligible"/>
          </coding>
        </category>
        <amount>
          <value value="110.00"/>
          <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="88.00"/>
          <currency value="USD"/>
        </amount>
      </adjudication>
      <subDetail>
        <subDetailSequence value="1"/>
        <noteNumber value="1"/>
        <adjudication>
          <category>
            <coding>
              <code value="eligible"/>
            </coding>
          </category>
          <amount>
            <value value="60.00"/>
            <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="48.00"/>
            <currency value="USD"/>
          </amount>
        </adjudication>
      </subDetail>
      <subDetail>
        <subDetailSequence value="2"/>
        <adjudication>
          <category>
            <coding>
              <code value="eligible"/>
            </coding>
          </category>
          <amount>
            <value value="30.00"/>
            <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="24.00"/>
            <currency value="USD"/>
          </amount>
        </adjudication>
      </subDetail>
      <subDetail>
        <subDetailSequence value="3"/>
        <noteNumber value="1"/>
        <adjudication>
          <category>
            <coding>
              <code value="eligible"/>
            </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>
          <amount>
            <value value="8.00"/>
            <currency value="USD"/>
          </amount>
        </adjudication>
      </subDetail>
    </detail>
    <detail>
      <detailSequence value="3"/>
      <noteNumber value="1"/>
      <adjudication>
        <category>
          <coding>
            <code value="eligible"/>
          </coding>
        </category>
        <amount>
          <value value="200.00"/>
          <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="14.00"/>
          <currency value="USD"/>
        </amount>
      </adjudication>
    </detail>
  </item>
  <total>
    <category>
      <coding>
        <code value="submitted"/>
      </coding>
    </category>
    <amount>
      <value value="235.40"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <code value="benefit"/>
      </coding>
    </category>
    <amount>
      <value value="182.00"/>
      <currency value="USD"/>
    </amount>
  </total>
  <!--  Payment details  -->
  <payment>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/ex-paymenttype"/>
        <code value="complete"/>
      </coding>
    </type>
    <adjustment>
      <value value="75.00"/>
      <currency value="USD"/>
    </adjustment>
    <adjustmentReason>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/payment-adjustment-reason"/>
        <code value="a002"/>
        <display value="Prior Overpayment"/>
      </coding>
    </adjustmentReason>
    <date value="2014-08-16"/>
    <amount>
      <value value="107.00"/>
      <currency value="USD"/>
    </amount>
    <identifier>
      <system value="http://thebenefitcompany.com/paymentidentifier"/>
      <value value="201416-123456"/>
    </identifier>
  </payment>
  <processNote>
    <number value="1"/>
    <type>
      <coding>
        <system value="http://hl7.org/fhir/note-type"/>
        <code value="display"/>
      </coding>
    </type>
    <text value="After hours surcharge declined"/>
    <language>
      <coding>
        <system value="urn:ietf:bcp:47"/>
        <code value="en-CA"/>
      </coding>
    </language>
  </processNote>
</ClaimResponse>