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

<id value="R3500"/>

<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://www.BenefitsInc.com/fhir/remittance"/>
        <value value="R3500"/>
</identifier>

<status value="active"/>

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

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

<insurer>
        <identifier>
                <system value="http://www.jurisdiction.org/insurers"/>
                <value value="555123"/>
        </identifier>
</insurer>

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

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

<request>
        <reference value="http://www.BenefitsInc.com/fhir/Claim/15476332402"/>
</request>

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

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

<payeeType>
        <coding>
                <system value="http://hl7.org/fhir/payeetype"/>
                <code value="provider"/>
        </coding>
</payeeType>

<!--  Adjudication details  -->

<item>

        <sequenceLinkId value="1"/> 

        <adjudication>
                <category>
                        <coding>
                                <code value="eligible"/>
                        </coding>
                </category>
                <amount>
                        <value value="135.57"/>
                        <system value="urn:iso:std:iso:4217"/>
                        <code value="USD"/>
                </amount>
        </adjudication>

        <adjudication>
                <category>
                        <coding>
                                <code value="copay"/>
                        </coding>
                </category>
                <amount>
                        <value value="10.00"/>
                        <system value="urn:iso:std:iso:4217"/>
                        <code value="USD"/>
                </amount>  
        </adjudication>

        <adjudication>
                <category>
                        <coding>
                                <code value="eligpercent"/>
                        </coding>
                </category>
                <value value="80.00"/>
        </adjudication>

        <adjudication>
                <category>
                        <coding>
                                <code value="benefit"/>
                        </coding>
                </category>
                <amount>
                        <value value="100.47"/>
                        <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="100.47"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
</totalBenefit>

<!--  Payment details  -->
<payment>
        <type>
                <coding>
                        <system value="http://hl7.org/fhir/ex-paymenttype"/>
                        <code value="complete"/>
                </coding>
        </type> 

        <date value="2014-08-31"/>

        <amount>
                <value value="100.47"/>
                <system value="urn:iso:std:iso:4217"/>
                <code value="USD"/>
        </amount>       

        <identifier>
                <system value="http://www.BenefitsInc.com/fhir/paymentidentifier"/>
                <value value="201408-2-1569478"/>
        </identifier>   
</payment>

</ClaimResponse>