<?xml version="1.0" encoding="UTF-8"?><ClaimResponse xmlns="http://hl7.org/fhir">

	<id value="R3502"/>

	<meta>
    <security>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActReason"/>
      <code value="HTEST"/>
      <display value="test health data"/>
    </security>
  </meta>
  <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"/>

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

	<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>

	  <!--  Adjudication details  -->

	<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 details  -->
	<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>