<?xml version="1.0" encoding="UTF-8"?><ClaimResponse xmlns="http://hl7.org/fhir"><id value="R3500"/><meta><tag><system value="http://terminology.hl7.org/CodeSystem/v3-ActReason"/><code value="HTEST"/><display value="fGcCRfRhJNQAgN"/></tag></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://www.BenefitsInc.com/fhir/remittance"/><value value="rBFhZtJTlROw1j1d"/></identifier><status value="active"/><type><coding><system value="http://terminology.hl7.org/CodeSystem/claim-type"/><code value="oral"/></coding></type><subType><coding><system value="http://terminology.hl7.org/CodeSystem/ex-claimsubtype"/><code value="emergency"/></coding></subType><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="Ik94PXcpKYDWqi39"/></identifier></insurer><requestor><reference value="Organization/1"/></requestor><request><reference value="http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402"/></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><item><itemSequence value="1"/><adjudication><category><coding><code value="eligible"/></coding></category><amount><value value="47446"/><currency value="USD"/></amount></adjudication><adjudication><category><coding><code value="copay"/></coding></category><amount><value value="36238"/><currency value="USD"/></amount></adjudication><adjudication><category><coding><code value="eligpercent"/></coding></category><value value="43278"/></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="nBnfWOuzQCWR6nSg"/></coding></reason><amount><value value="95225"/><currency value="USD"/></amount></adjudication></item><total><category><coding><code value="submitted"/></coding></category><amount><value value="64052"/><currency value="USD"/></amount></total><total><category><coding><code value="benefit"/></coding></category><amount><value value="64106"/><currency value="USD"/></amount></total><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="36874"/><currency value="USD"/></amount><identifier><system value="http://www.BenefitsInc.com/fhir/paymentidentifier"/><value value="URbWY9kz0ZMf"/></identifier></payment></ClaimResponse>