<?xml version="1.0" encoding="UTF-8"?>

<Claim xmlns="http://hl7.org/fhir">  
    <id value="C6AMWGGA3GB4ARUD"/>  
    <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">  
            <p>Touchstone Test Data - Touchstone Test Data - Claim: Pre-Authorization Vision Claim</p> 
        </div> 
    </text>  
    <identifier> 
        <system value="http://happysight.com/claim"/>  
        <value value="131188874-575769"/> 
    </identifier>  
    <status value="draft"/>  
    <type> 
        <coding> 
            <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>  
            <code value="vision"/> 
        </coding> 
    </type>  
    <use value="preauthorization"/>  
    <patient> 
        <reference value="Patient/C6AMWGBVX4SNUELP"/> 
    </patient>  
    <created value="2018-12-13"/>  
    <insurer> 
        <identifier> 
            <system value="http://benefitsinc.com/insurer"/>  
            <value value="6LyrBteu4C-N1I2kTTcyJCL"/> 
        </identifier>  
        <display value="6LyrBteu4C-N1I2kTTcyJCL"/> 
    </insurer>  
    <provider> 
        <identifier> 
            <system value="http://benefitsinc.com/responsible"/>  
            <value value="6LyrBteu4C-c6yk00gOlZL"/> 
        </identifier>  
        <display value="6LyrBteu4C-c6yk00gOlZL"/> 
    </provider>  
    <priority> 
        <coding> 
            <code value="deferred"/> 
        </coding> 
    </priority>  
    <payee> 
        <type> 
            <coding> 
                <code value="Subscriber"/> 
            </coding> 
        </type> 
    </payee>  
    <careTeam> 
        <sequence value="1"/>  
        <provider> 
            <identifier> 
                <system value="http://benefitsinc.com/responsible"/>  
                <value value="6LyrBteu4C-c6yk00gOlZL"/> 
            </identifier>  
            <display value="6LyrBteu4C-c6yk00gOlZL"/> 
        </provider> 
    </careTeam>  
    <diagnosis> 
        <sequence value="1"/>  
        <diagnosisCodeableConcept> 
            <coding> 
                <code value="65692"/> 
            </coding> 
        </diagnosisCodeableConcept> 
    </diagnosis>  
    <insurance> 
        <sequence value="1"/>  
        <focal value="true"/>  
        <coverage> 
            <reference value="Coverage/C6AMWGDWKN72Y6GP"/> 
        </coverage> 
    </insurance>  
    <item> 
        <sequence value="1"/>  
        <productOrService> 
            <coding> 
                <system value="http://terminology.hl7.org/CodeSystem/ex-USCLS"/>  
                <code value="1101"/>  
                <display value="Exam, comp, primary"/> 
            </coding> 
        </productOrService>  
        <servicedDate value="2018-12-13"/>  
        <unitPrice> 
            <value value="80.00"/>  
            <currency value="USD"/> 
        </unitPrice>  
        <net> 
            <value value="80.00"/>  
            <currency value="USD"/> 
        </net> 
    </item> 
</Claim>