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

<ClaimResponse xmlns="http://hl7.org/fhir">  
    <id value="C6AMWI2NVDPH3NXY"/>  
    <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 - ClaimResponse: Pre-authorization Vision Claim Response</p> 
        </div> 
    </text>  
    <identifier> 
        <system value="http://benefitsinc.com/remittance"/>  
        <value value="3788109874-575769"/> 
    </identifier>  
    <status value="active"/>  
    <type> 
        <coding> 
            <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>  
            <code value="vision"/> 
        </coding> 
    </type>  
    <use value="claim"/>  
    <patient> 
        <identifier> 
            <system value="http://happysight.com/patient"/>  
            <value value="3788109874-575769-2904979"/> 
        </identifier>  
        <display value="3788109874-575769-2904979"/> 
    </patient>  
    <created value="2018-12-28"/>  
    <insurer> 
        <identifier> 
            <system value="http://benefitsinc.com/certificate"/>  
            <value value="Pm1Yvlg7kvBiFq7wj2904979"/> 
        </identifier>  
        <display value="Pm1Yvlg7kvBiFq7wj2904979"/> 
    </insurer>  
    <request> 
        <identifier> 
            <system value="http://happysight.com/claim"/>  
            <value value="Pm1Yvlg7kvBiFq7wj"/> 
        </identifier>  
        <display value="Pm1Yvlg7kvBiFq7wj"/> 
    </request>  
    <outcome value="partial"/>  
    <disposition value="Pre-authorization completed as per coverage Pm1Yvlg7kvBiFq7wj575769."/>  
    <payeeType> 
        <coding> 
            <system value="http://terminology.hl7.org/CodeSystem/payeetype"/>  
            <code value="subscriber"/> 
        </coding> 
    </payeeType>  
    <item> 
        <itemSequence value="1"/>  
        <adjudication> 
            <category> 
                <coding> 
                    <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>  
                    <code value="eligible"/> 
                </coding> 
            </category>  
            <amount> 
                <value value="80.00"/>  
                <currency value="USD"/> 
            </amount> 
        </adjudication>  
        <adjudication> 
            <category> 
                <coding> 
                    <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>  
                    <code value="copay"/> 
                </coding> 
            </category>  
            <amount> 
                <value value="10.00"/>  
                <currency value="USD"/> 
            </amount> 
        </adjudication>  
        <adjudication> 
            <category> 
                <coding> 
                    <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>  
                    <code value="eligpercent"/> 
                </coding> 
            </category>  
            <value value="100.00"/> 
        </adjudication>  
        <adjudication> 
            <category> 
                <coding> 
                    <system value="http://terminology.hl7.org/CodeSystem/adjudication"/>  
                    <code value="benefit"/> 
                </coding> 
            </category>  
            <amount> 
                <value value="70.00"/>  
                <currency value="USD"/> 
            </amount> 
        </adjudication> 
    </item>  
    <total> 
        <category> 
            <coding> 
                <code value="submitted"/> 
            </coding> 
        </category>  
        <amount> 
            <value value="80.00"/>  
            <currency value="USD"/> 
        </amount> 
    </total>  
    <total> 
        <category> 
            <coding> 
                <code value="benefit"/> 
            </coding> 
        </category>  
        <amount> 
            <value value="70.00"/>  
            <currency value="USD"/> 
        </amount> 
    </total>  
    <payment> 
        <type> 
            <coding> 
                <system value="http://terminology.hl7.org/CodeSystem/ex-paymenttype"/>  
                <code value="complete"/> 
            </coding> 
        </type>  
        <date value="2018-12-28"/>  
        <amount> 
            <value value="70.00"/>  
            <currency value="USD"/> 
        </amount>  
        <identifier> 
            <system value="http://benefitsinc.com/paymentidentifier"/>  
            <value value="575769-2904979"/> 
        </identifier> 
    </payment> 
</ClaimResponse>