<?xml version="1.0" encoding="UTF-8"?><Claim xmlns="http://hl7.org/fhir">
  <id value="100153"/>
  <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 Oral Health Claim</div>
  </text>
  <identifier>
    <system value="http://happyvalley.com/claim"/>
    <value value="12355"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="oral"/>
    </coding>
  </type>
  <use value="preauthorization"/>
  <subject>
    <reference value="Patient/1"/>
  </subject>
  <created value="2015-03-16"/>
  <insurer>
    <reference value="Organization/2"/>
  </insurer>
  <provider>
    <reference value="Organization/1"/>
  </provider>
  <priority>
    <coding>
      <code value="normal"/>
    </coding>
  </priority>
  <fundsReserve>
    <coding>
      <code value="provider"/>
    </coding>
  </fundsReserve>
  <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>
        <system value="http://hl7.org/fhir/sid/icd-10"/>
        <!--  <code value="123457"/>  -->
        <code value="K07.3"/>
      </coding>
    </diagnosisCodeableConcept>
  </diagnosis>
  <insurance>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/9876B1"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <careTeamSequence value="1"/>
    <diagnosisSequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://example.org/fhir/oralservicecodes"/>
        <code value="ORTHPLAN"/>
      </coding>
    </productOrService>
    <servicedDate value="2015-05-16"/>
    <!--  Start Date  -->
    <unitPrice>
      <value value="9000.00"/>
      <currency value="USD"/>
    </unitPrice>
    <net>
      <value value="9000.00"/>
      <currency value="USD"/>
    </net>
    <detail>
      <sequence value="1"/>
      <!--  Exam Fee  -->
      <productOrService>
        <coding>
          <system value="http://example.org/fhir/oralservicecodes"/>
          <code value="ORTHOEXAM"/>
        </coding>
      </productOrService>
      <unitPrice>
        <value value="1000.00"/>
        <currency value="USD"/>
      </unitPrice>
      <net>
        <value value="1000.00"/>
        <currency value="USD"/>
      </net>
    </detail>
    <detail>
      <sequence value="2"/>
      <!--  Diagnostic Fee  -->
      <productOrService>
        <coding>
          <system value="http://example.org/fhir/oralservicecodes"/>
          <code value="ORTHODIAG"/>
        </coding>
      </productOrService>
      <unitPrice>
        <value value="1500.00"/>
        <currency value="USD"/>
      </unitPrice>
      <net>
        <value value="1500.00"/>
        <currency value="USD"/>
      </net>
    </detail>
    <detail>
      <sequence value="3"/>
      <!--  Initial Payment  -->
      <productOrService>
        <coding>
          <system value="http://example.org/fhir/oralservicecodes"/>
          <code value="ORTHOINITIAL"/>
        </coding>
      </productOrService>
      <unitPrice>
        <value value="500.00"/>
        <currency value="USD"/>
      </unitPrice>
      <net>
        <value value="500.00"/>
        <currency value="USD"/>
      </net>
    </detail>
    <detail>
      <sequence value="4"/>
      <!--  Duration in Months  -->
      <productOrService>
        <coding>
          <system value="http://example.org/fhir/oralservicecodes"/>
          <code value="ORTHOMONTHS"/>
        </coding>
      </productOrService>
      <quantity>
        <value value="24"/>
      </quantity>
    </detail>
    <detail>
      <sequence value="5"/>
      <!--  Periodic Payments  -->
      <productOrService>
        <coding>
          <system value="http://example.org/fhir/oralservicecodes"/>
          <code value="ORTHOPERIODIC"/>
        </coding>
      </productOrService>
      <quantity>
        <value value="24"/>
      </quantity>
      <unitPrice>
        <value value="250.00"/>
        <currency value="USD"/>
      </unitPrice>
      <net>
        <value value="250.00"/>
        <currency value="USD"/>
      </net>
    </detail>
  </item>
  <item>
    <sequence value="2"/>
    <careTeamSequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://example.org/fhir/oralservicecodes"/>
        <code value="21211"/>
      </coding>
    </productOrService>
    <servicedDate value="2014-08-16"/>
    <unitPrice>
      <value value="105.00"/>
      <currency value="USD"/>
    </unitPrice>
    <net>
      <value value="105.00"/>
      <currency value="USD"/>
    </net>
    <bodySite>
      <site>
        <concept>
          <coding>
            <system value="http://fdi.org/fhir/oraltoothcodes"/>
            <code value="21"/>
          </coding>
        </concept>
      </site>
      <subSite>
        <coding>
          <system value="http://fdi.org/fhir/oralsurfacecodes"/>
          <code value="L"/>
        </coding>
      </subSite>
    </bodySite>
  </item>
  <item>
    <sequence value="3"/>
    <careTeamSequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://example.org/fhir/oralservicecodes"/>
        <code value="27211"/>
      </coding>
    </productOrService>
    <servicedDate value="2014-08-16"/>
    <unitPrice>
      <value value="1100.00"/>
      <currency value="USD"/>
    </unitPrice>
    <net>
      <value value="1100.00"/>
      <currency value="USD"/>
    </net>
    <bodySite>
      <site>
        <concept>
          <coding>
            <system value="http://fdi.org/fhir/oraltoothcodes"/>
            <code value="36"/>
          </coding>
        </concept>
      </site>
    </bodySite>
    <detail>
      <sequence value="1"/>
      <productOrService>
        <coding>
          <system value="http://example.org/fhir/oralservicecodes"/>
          <code value="27211"/>
        </coding>
      </productOrService>
      <unitPrice>
        <value value="750.00"/>
        <currency value="USD"/>
      </unitPrice>
      <net>
        <value value="750.00"/>
        <currency value="USD"/>
      </net>
    </detail>
    <detail>
      <sequence value="2"/>
      <productOrService>
        <coding>
          <system value="http://example.org/fhir/oralservicecodes"/>
          <code value="lab"/>
        </coding>
      </productOrService>
      <unitPrice>
        <value value="350.00"/>
        <currency value="USD"/>
      </unitPrice>
      <net>
        <value value="350.00"/>
        <currency value="USD"/>
      </net>
    </detail>
  </item>
</Claim>