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

<id value="100152"/>
<text>
  <status value="generated"/>
  <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the Oral Health Claim</div>
</text>

<contained>
  <Organization>
    <id value="org-insurer"/>
    <identifier>
      <system value="http://www.bindb.com/bin"/>
      <value value="123456"/>
    </identifier>
  </Organization>
</contained>

<contained>
  <Organization>
    <id value="org-org"/>
    <identifier>
      <system value="http://www.jurisdiction.com/oralhealthoffices"/>
      <value value="3456"/>
    </identifier>
  </Organization>
</contained>

<contained>
  <Practitioner>
    <id value="provider-1"/>
    <identifier>
      <system value="http://www.jurisdiction.com/oralhealthproviders"/>
      <value value="123456789"/>
    </identifier>
  </Practitioner>
</contained>

<contained>
  <Patient>
    <id value="patient-1"/>
    <name>
      <use value="official"/>
      <family value="Donald"/>
      <given value="Duck"/>
    </name>
    <gender value="male"/>
    <birthDate value="1986-05-17"/>
    <address>
      <use value="home"/>
      <line value="1234 Main Street"/>
      <city value="Vancouver"/>
      <postalCode value="V2H1Y3"/>
      <country value="CAD"/>
    </address>
  </Patient>
</contained>

<contained>
  <Coverage>
    <id value="coverage-1"/>

    <identifier>
      <system value="http://benefitsinc.com/certificate"/>
      <value value="12345"/>
    </identifier>

    <status value="active"/>

    <type>
         <coding>
      <system value="http://hl7.org/fhir/v3/ActCode"/>
      <code value="EHCPOL"/>
     </coding>
        </type>

    <subscriber>
      <reference value="#patient-1"/>
    </subscriber>

    <beneficiary>
      <reference value="#patient-1"/>
    </beneficiary>

    <relationship>
         <coding>
      <code value="self"/>
     </coding>
        </relationship>

    <payor>
          <identifier>
        <system value="http://www.bindb.com/bin"/>
        <value value="123456"/>
          </identifier>
    </payor>

        <grouping>
          <plan value="CBI35"/>
      <planDisplay value="Corporate Baker&#39;s Inc. Plan#35"/>
      <subPlan value="123"/>
      <subPlanDisplay value="Trainee Part-time Benefits"/>
        </grouping> 

    <dependent value="1"/>
    <sequence value="1"/>
  </Coverage>
</contained>

<identifier>
  <system value="http://happyvalley.com/claim"/>
  <value value="12347"/>
</identifier>

<status value="active"/>

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

<use value="complete"/>

<patient>
  <reference value="#patient-1"/>
</patient>

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

<insurer>
  <reference value="#org-insurer"/>
</insurer>

<organization>
  <reference value="#org-org"/>
</organization>  

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

<payee>
  <type>
       <coding>
    <code value="provider"/>
   </coding>
      </type>
</payee>

 <careTeam>
  <sequence value="1"/>
  <provider>
    <reference value="#provider-1"/>
  </provider>
 </careTeam>

<diagnosis>
  <sequence value="1"/>
  <diagnosisCodeableConcept>
       <coding>
    <code value="123456"/>
   </coding>
      </diagnosisCodeableConcept>
</diagnosis>

<insurance>
  <sequence value="1"/>
  <focal value="true"/>
  <coverage>
    <reference value="#coverage-1"/>
  </coverage>
</insurance>

<item>
  <sequence value="1"/>
  <careTeamLinkId value="1"/>
  <service>
       <coding>
    <code value="1200"/>
   </coding>
      </service>
  <servicedDate value="2014-08-16"/>
  <unitPrice>
    <value value="135.57"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </unitPrice>
  <net>
    <value value="135.57"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </net>
</item>

</Claim>