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

	<id value="R3503"/>

	<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 to Claim Oral Average with additional items</div>
	</text>

	<identifier>
		<system value="http://www.BenefitsInc.com/fhir/remittance"/>
		<value value="R3503"/>
	</identifier>

	<status value="active"/>

	<type>
		<coding>
			<system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
			<code value="oral"/>
		</coding>
	</type>

	<use value="claim"/>

	<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>

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

	<request>
		<identifier>
			<system value="http://happyvalley.com/claim"/>
			<value value="12346"/>
		</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>   <!--  Pays for a claim package code with two actual codes with adjudication details  -->

		<itemSequence value="1"/> 

		<adjudication>
			<category>
				<coding>
					<code value="eligible"/>
				</coding>
			</category>
			<amount>
				<value value="0.00"/>
				<currency value="USD"/>
			</amount>
		</adjudication>
		<adjudication>
			<category>
				<coding>
					<code value="benefit"/>
				</coding>
			</category>
			<amount>
				<value value="0.00"/>
				<currency value="USD"/>
			</amount>	
		</adjudication>

	</item>

	<item>
		<itemSequence value="2"/> 

		<adjudication>
			<category>
				<coding>
					<code value="eligible"/>
				</coding>
			</category>
			<amount>
				<value value="105.00"/>
				<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="84.00"/>
				<currency value="USD"/>
			</amount>	
		</adjudication>

	</item>

	<item>
		<itemSequence value="3"/> 

		<adjudication>
			<category>
				<coding>
					<code value="eligible"/>
				</coding>
			</category>
			<amount>
				<value value="750.00"/>
				<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="600.00"/>
				<currency value="USD"/>
			</amount>	
		</adjudication>

		<detail>
			<detailSequence value="1"/> 

			<adjudication>
				<category>
					<coding>
						<code value="eligible"/>
					</coding>
				</category>
				<amount>
					<value value="750.00"/>
					<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="600.00"/>
					<currency value="USD"/>
				</amount>	
			</adjudication>

		</detail>
		<detail>    <!--  See the addItem.detail below  -->
			<detailSequence value="2"/> 

			<adjudication>
				<category>
					<coding>
						<code value="eligible"/>
					</coding>
				</category>
				<amount>
					<value value="0.00"/>
					<currency value="USD"/>
				</amount>
			</adjudication>

			<adjudication>
				<category>
					<coding>
						<code value="benefit"/>
					</coding>
				</category>
				<amount>
					<value value="0.00"/>
					<currency value="USD"/>
				</amount>	
			</adjudication>

		</detail>
	</item>


	  <!--  Pays for a claim package code (1200) with two actual codes (1101, 2141) with adjudication details  -->
	<addItem>
		<itemSequence value="1"/> 
		<productOrService>
			<coding>
				<system value="http://example.org/fhir/oralservicecodes"/>
				<code value="1101"/>
			</coding>
		</productOrService>
		<modifier>
			<coding>
				<system value="http://example.org/fhir/modifiers"/>
				<code value="x"/>
				<display value="None"/>
			</coding>
		</modifier>
		<net>
			<value value="135.57"/>
			<currency value="USD"/>
		</net>
		<noteNumber value="101"/>
		<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="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>
			<reason>
				<coding>
					<system value="http://terminology.hl7.org/CodeSystem/adjudication-reason"/>
					<code value="ar002"/>
					<display value="Plan Limit Reached"/>
					  <!--  should have paid 100.47  -->
				</coding>
			</reason>
			<amount>
				<value value="72.00"/>
				<currency value="USD"/>
			</amount>	
		</adjudication>

	</addItem>
	<addItem>
		<itemSequence value="1"/> 
		<productOrService>
			<coding>
				<system value="http://example.org/fhir/oralservicecodes"/>
				<code value="2141"/>
				<display value="Radiograph, bytewing"/>
			</coding>
		</productOrService>
		<net>
			<value value="35.57"/>
			<currency value="USD"/>
		</net>
		<adjudication>
			<category>
				<coding>
					<code value="eligible"/>
				</coding>
			</category>
			<amount>
				<value value="35.57"/>
				<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="28.47"/>
				<currency value="USD"/>
			</amount>	
		</adjudication>
	</addItem>

	  <!--  Pays for a claim package code (1200) with two actual codes (1101, 2141) with adjudication details  -->
	<addItem>
		<itemSequence value="3"/> 
		<detailSequence value="2"/>
		<productOrService>
			<coding>
				<system value="http://example.org/fhir/oralservicecodes"/>
				<code value="expense"/>
			</coding>
		</productOrService>
		<modifier>
			<coding>
				<system value="http://example.org/fhir/modifiers"/>
				<code value="x"/>
				<display value="None"/>
			</coding>
		</modifier>
		<net>
			<value value="350.00"/>
			<currency value="USD"/>
		</net>
		<noteNumber value="101"/>
		<adjudication>
			<category>
				<coding>
					<code value="eligible"/>
				</coding>
			</category>
			<amount>
				<value value="350.00"/>
				<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="270.00"/>
				<currency value="USD"/>
			</amount>	
		</adjudication>

	</addItem>

	<total>
		<category>
			<coding>
				<code value="submitted"/>
			</coding>
		</category>
		<amount>
			<value value="1340.57"/>
			<currency value="USD"/> 
		</amount> 
	</total>
	
	<total>
		<category>
			<coding>
				<code value="benefit"/>
			</coding>
		</category>
		<amount>
			<value value="1054.47"/>
			<currency value="USD"/> 
		</amount> 
	</total>

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

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

		<amount>
			<value value="100.47"/>
			<currency value="USD"/>
		</amount>	

		<identifier>
			<system value="http://www.BenefitsInc.com/fhir/paymentidentifier"/>
			<value value="201408-2-15507"/>
		</identifier>	
	</payment>

	<processNote>
		<number value="101"/>
		<type>
			<coding>
				<system value="http://hl7.org/fhir/note-type"/>
				<code value="print"/>
			</coding>
		</type>
		<text value="Package codes are not permitted. Codes replaced by Insurer."/>
		<language>
			<coding>
				<system value="urn:ietf:bcp:47"/>
				<code value="en-CA"/>
			</coding>
		</language>
	</processNote>	
</ClaimResponse>