<ClaimResponse xmlns="http://hl7.org/fhir"><id value="R3502"/><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><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><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>