<?xml version=“1.0” encoding=“UTF-8”?><Claim xmlns=“hl7.org/fhir”>

<id value="660152"/>

<text>
        <status value="generated"/>
        <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the Vision Claim for Glasses</div>
</text>

<contained>
        <ClaimResponse>
                <id value="claimresponse-1"/>

                <identifier>
                        <system value="http://thebenefircompany.com/claimresponse"/>
                        <value value="CR6532875367"/>
                </identifier>

                <!--  rest of the resource ommitted for brevity  -->

        </ClaimResponse>
</contained>

<contained>
        <Device>
                <id value="device-frame"/>
                <!--  rest of the resource ommitted for brevity  -->
        </Device>
</contained>

<contained>
        <Device>
                <id value="device-lens"/>
                <!--  rest of the resource ommitted for brevity  -->
        </Device>
</contained>

<identifier>
        <system value="http://happysight.com/claim"/>
        <value value="6612347"/>
</identifier>

<status value="active"/>

<type>
        <coding>
                <system value="http://hl7.org/fhir/ex-claimtype"/>
                <code value="vision"/>
        </coding>
</type>

<use value="complete"/>

<patient>
        <reference value="Patient/1"/>
</patient>

<created value="2014-08-16"/>

<insurer>
        <reference value="Organization/2"/>
</insurer>

<organization>
        <reference value="Organization/1"/>
</organization>

<priority>
        <coding>
                <code value="normal"/>
        </coding>
</priority>

<prescription>
        <reference value="http://www.optdocs.com/VisionPrescription/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-1"/>
        </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"/>
        <careTeamLinkId value="1"/>
        <revenue>
                <coding>
                        <system value="http://hl7.org/fhir/ex-revenue-center"/>
                        <code value="0010"/>
                        <display value="Vision Clinic"/>
                </coding>
        </revenue>
        <category>
                <coding>
                        <system value="http://hl7.org/fhir/benefit-subcategory"/>
                        <code value="F6"/>
                        <display value="Vision Coverage"/>
                </coding>
        </category>
        <service>
                <coding>
                        <system value="http://hl7.org/fhir/ex-visionservice"/>
                        <code value="glasses"/>
                </coding>
        </service>
        <modifier>
                <coding>
                        <system value="http://hl7.org/fhir/modifiers"/>
                        <code value="rooh"/>
                </coding>
        </modifier>
        <programCode>
                <coding>
                        <system value="http://hl7.org/fhir/ex-programcode"/>
                        <code value="none"/>
                </coding>
        </programCode>  
        <servicedDate value="2014-08-16"/>
        <unitPrice>
                <value value="235.40"/>
                <system value="urn:iso:std:iso:4217"/>
                <code value="USD"/> 
        </unitPrice> 
        <net>
                <value value="235.40"/>
                <system value="urn:iso:std:iso:4217"/>
                <code value="USD"/> 
        </net> 

        <detail>
                <sequence value="1"/>
                <revenue>
                        <coding>
                                <system value="http://hl7.org/fhir/ex-revenue-center"/>
                                <code value="0010"/>
                                <display value="Vision Clinic"/>
                        </coding>
                </revenue>
                <category>
                        <coding>
                                <system value="http://hl7.org/fhir/benefit-subcategory"/>
                                <code value="F6"/>
                                <display value="Vision Coverage"/>
                        </coding>
                </category>
                <service>
                        <coding>
                                <system value="http://hl7.org/fhir/ex-visionservice"/>
                                <code value="frame"/>
                        </coding>
                </service>
                <modifier>
                        <coding>
                                <system value="http://hl7.org/fhir/modifiers"/>
                                <code value="rooh"/>
                        </coding>
                </modifier>
                <unitPrice>
                        <value value="100.00"/>
                        <system value="urn:iso:std:iso:4217"/>
                        <code value="USD"/> 
                </unitPrice> 
                <factor value="1.1"/> <!--  10% surchage for out of hours work  -->
                <net>
                        <value value="110.00"/>
                        <system value="urn:iso:std:iso:4217"/>
                        <code value="USD"/> 
                </net> 
                <udi>
                        <reference value="#device-frame"/>
                </udi>
        </detail>

        <detail>
                <sequence value="2"/>
                <revenue>
                        <coding>
                                <system value="http://hl7.org/fhir/ex-revenue-center"/>
                                <code value="0010"/>
                                <display value="Vision Clinic"/>
                        </coding>
                </revenue>
                <category>
                        <coding>
                                <system value="http://hl7.org/fhir/benefit-subcategory"/>
                                <code value="F6"/>
                                <display value="Vision Coverage"/>
                        </coding>
                </category>
                <service>
                        <coding>
                                <system value="http://hl7.org/fhir/ex-visionservice"/>
                                <code value="lens"/>
                        </coding>
                </service>
                <programCode>
                        <coding>
                                <system value="http://hl7.org/fhir/ex-programcode"/>
                                <code value="none"/>
                        </coding>
                </programCode>  
                <quantity>
                        <value value="2"/>
                </quantity>
                <unitPrice>
                        <value value="55.00"/>
                        <system value="urn:iso:std:iso:4217"/>
                        <code value="USD"/> 
                </unitPrice> 
                <net>
                        <value value="110.00"/>
                        <system value="urn:iso:std:iso:4217"/>
                        <code value="USD"/> 
                </net> 

                <subDetail>
                        <sequence value="1"/>
                        <revenue>
                                <coding>
                                        <system value="http://hl7.org/fhir/ex-revenue-center"/>
                                        <code value="0010"/>
                                        <display value="Vision Clinic"/>
                                </coding>
                        </revenue>
                        <category>
                                <coding>
                                        <system value="http://hl7.org/fhir/benefit-subcategory"/>
                                        <code value="F6"/>
                                        <display value="Vision Coverage"/>
                                </coding>
                        </category>
                        <service>
                                <coding>
                                        <system value="http://hl7.org/fhir/ex-visionservice"/>
                                        <code value="lens"/>
                                </coding>
                        </service>
                        <modifier>
                                <coding>
                                        <system value="http://hl7.org/fhir/modifiers"/>
                                        <code value="rooh"/>
                                </coding>
                        </modifier>
                        <programCode>
                                <coding>
                                        <system value="http://hl7.org/fhir/ex-programcode"/>
                                        <code value="none"/>
                                </coding>
                        </programCode>  
                        <quantity>
                                <value value="2"/>
                        </quantity>
                        <unitPrice>
                                <value value="30.00"/>
                                <system value="urn:iso:std:iso:4217"/>
                                <code value="USD"/> 
                        </unitPrice> 
                        <factor value="1.1"/> <!--  10% surchage for out of hours work  -->
                        <net>
                                <value value="66.00"/>
                                <system value="urn:iso:std:iso:4217"/>
                                <code value="USD"/> 
                        </net> 
                        <udi>
                                <reference value="#device-lens"/>
                        </udi>
                </subDetail>

                <subDetail>
                        <sequence value="2"/>
                        <revenue>
                                <coding>
                                        <system value="http://hl7.org/fhir/ex-revenue-center"/>
                                        <code value="0010"/>
                                        <display value="Vision Clinic"/>
                                </coding>
                        </revenue>
                        <category>
                                <coding>
                                        <system value="http://hl7.org/fhir/benefit-subcategory"/>
                                        <code value="F6"/>
                                        <display value="Vision Coverage"/>
                                </coding>
                        </category>
                        <service>
                                <coding>
                                        <system value="http://hl7.org/fhir/ex-visionservice"/>
                                        <code value="hardening"/>
                                </coding>
                        </service>
                        <modifier>
                                <coding>
                                        <system value="http://hl7.org/fhir/modifiers"/>
                                        <code value="rooh"/>
                                </coding>
                        </modifier>
                        <quantity>
                                <value value="2"/>
                        </quantity>
                        <unitPrice>
                                <value value="15.00"/>
                                <system value="urn:iso:std:iso:4217"/>
                                <code value="USD"/> 
                        </unitPrice> 
                        <factor value="1.1"/> <!--  10% surchage for out of hours work  -->
                        <net>
                                <value value="33.00"/>
                                <system value="urn:iso:std:iso:4217"/>
                                <code value="USD"/> 
                        </net> 
                </subDetail>

                <subDetail>
                        <sequence value="3"/>
                        <revenue>
                                <coding>
                                        <system value="http://hl7.org/fhir/ex-revenue-center"/>
                                        <code value="0010"/>
                                        <display value="Vision Clinic"/>
                                </coding>
                        </revenue>
                        <category>
                                <coding>
                                        <system value="http://hl7.org/fhir/benefit-subcategory"/>
                                        <code value="F6"/>
                                        <display value="Vision Coverage"/>
                                </coding>
                        </category>
                        <service>
                                <coding>
                                        <system value="http://hl7.org/fhir/ex-visionservice"/>
                                        <code value="UV coating"/>
                                </coding>
                        </service>
                        <modifier>
                                <coding>
                                        <system value="http://hl7.org/fhir/modifiers"/>
                                        <code value="rooh"/>
                                </coding>
                        </modifier>
                        <quantity>
                                <value value="2"/>
                        </quantity>
                        <unitPrice>
                                <value value="5.00"/>
                                <system value="urn:iso:std:iso:4217"/>
                                <code value="USD"/> 
                        </unitPrice> 
                        <factor value="1.1"/> <!--  10% surchage for out of hours work  -->
                        <net>
                                <value value="11.00"/>
                                <system value="urn:iso:std:iso:4217"/>
                                <code value="USD"/> 
                        </net> 
                </subDetail>
        </detail>

        <detail>
                <sequence value="3"/>
                <revenue>
                        <coding>
                                <system value="http://hl7.org/fhir/ex-revenue-center"/>
                                <code value="0010"/>
                                <display value="Vision Clinic"/>
                        </coding>
                </revenue>
                <category>
                        <coding>
                                <system value="http://hl7.org/fhir/benefit-subcategory"/>
                                <code value="F6"/>
                                <display value="Vision Coverage"/>
                        </coding>
                </category>
                <service>
                        <coding>
                                <system value="http://hl7.org/fhir/ex-visionservice"/>
                                <code value="fst"/>
                        </coding>
                </service>
                <unitPrice>
                        <value value="220.00"/>
                        <system value="urn:iso:std:iso:4217"/>
                        <code value="USD"/> 
                </unitPrice> 
                <factor value="0.07"/>
                <net>
                        <value value="15.40"/>
                        <system value="urn:iso:std:iso:4217"/>
                        <code value="USD"/> 
                </net> 
        </detail>
</item>

</Claim>