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

<id value="EB3500"/>

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

<identifier>
        <system value="http://www.BenefitsInc.com/fhir/explanationofbenefit"/>
        <value value="987654321"/>
</identifier>

<status value="active"/>

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

<patient>
        <reference value="Patient/pat1"/>
</patient>

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

<enterer>
        <reference value="Practitioner/1"/>
</enterer>

<provider>
        <reference value="Practitioner/1"/>
</provider>

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

<facility>
        <reference value="Location/1"/>
</facility>

<claim>
        <reference value="Claim/100150"/>
</claim>

<claimResponse>
        <reference value="ClaimResponse/R3500"/>
</claimResponse> 

<outcome>
        <coding>
                <system value="http://hl7.org/fhir/remittance-outcome"/>
                <code value="complete"/>
        </coding>
</outcome>

<disposition value="Claim settled as per contract."/>

<payee>
        <type>
                <coding>
                        <system value="http://hl7.org/fhir/payeetype"/>
                        <code value="provider"/>
                </coding>
        </type>
        <resourceType>
                <coding>
                        <system value="http://hl7.org/fhir/resource-type-link"/>
                        <code value="organization"/>
                </coding>
        </resourceType>
        <party>
                <reference value="Organization/2"/>
        </party>
</payee>

<careTeam>
        <sequence value="1"/>
        <provider>
                <reference value="Practitioner/example"/>
        </provider>
</careTeam>

<insurance>
        <coverage>
                <reference value="Coverage/9876B1"/>
        </coverage>
</insurance>

<item>
        <sequence value="1"/>
        <careTeamLinkId value="1"/>
        <service>
                <coding>
                        <system value="http://hl7.org/fhir/service-uscls"/>
                        <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> 
        <encounter>
                <reference value="Encounter/example"/>
        </encounter>
        <adjudication>
                <category>
                        <coding>
                                <code value="eligible"/>
                        </coding>
                </category>
                <amount>
                        <value value="120.00"/>
                        <system value="urn:iso:std:iso:4217"/>
                        <code value="USD"/> 
                </amount> 
        </adjudication>
        <adjudication>
                <category>
                        <coding>
                                <code value="eligpercent"/>
                        </coding>
                </category>
                <value value="0.80"/>
        </adjudication>
        <adjudication>
                <category>
                        <coding>
                                <code value="benefit"/>
                        </coding>
                </category>
                <amount>
                        <value value="96.00"/>
                        <system value="urn:iso:std:iso:4217"/>
                        <code value="USD"/> 
                </amount> 
        </adjudication>
</item>

<totalCost>
        <value value="135.57"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/> 
</totalCost>

<totalBenefit>
        <value value="96.00"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/> 
</totalBenefit>

</ExplanationOfBenefit>