<?xml version="1.0"?>
<Claim.Submission xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:xsd="http://www.w3.org/2001/XMLSchema">
  <Header>
    <SenderID>DHA-F-0045607</SenderID>
    <ReceiverID>TPA002</ReceiverID>
    <TransactionDate>02/12/2023 12:10</TransactionDate>
    <RecordCount>2</RecordCount>
    <DispositionFlag>TEST</DispositionFlag>
  </Header>
  <Claim>
    <ID>TPA002_INS008_02_12_2023_24579_AP0203922</ID>
    <MemberID>62D3-5833-DAA1-D53E</MemberID>
    <PayerID>INS008</PayerID>
    <ProviderID>DHA-F-0045607</ProviderID>
    <EmiratesIDNumber>784-1979-9193542-6</EmiratesIDNumber>
    <Gross>790.80</Gross>
    <PatientShare>20.0</PatientShare>
    <Net>770.80</Net>
    <Encounter>
      <FacilityID>DHA-F-0045607</FacilityID>
      <Type>1</Type>
      <PatientID>AP0203922</PatientID>
      <Start>02/12/2023 00:00</Start>
      <End>02/12/2023 00:00</End>
      <StartType>1</StartType>
      <EndType>1</EndType>
    </Encounter>
    <Diagnosis>
      <Type>Principal</Type>
      <Code>A68.9</Code>
    </Diagnosis>
    <Diagnosis>
      <Type>Secondary</Type>
      <Code>J00</Code>
    </Diagnosis>
    <Diagnosis>
      <Type>Secondary</Type>
      <Code>L20.9</Code>
    </Diagnosis>
    <Diagnosis>
      <Type>Secondary</Type>
      <Code>L30.3</Code>
    </Diagnosis>
    <Diagnosis>
      <Type>Secondary</Type>
      <Code>M17.0</Code>
    </Diagnosis>
    <Diagnosis>
      <Type>Secondary</Type>
      <Code>A01.02</Code>
    </Diagnosis>
    <Diagnosis>
      <Type>Secondary</Type>
      <Code>K04.02</Code>
    </Diagnosis>
    <Activity>
      <ID>1</ID>
      <Start>02/12/2023 00:00</Start>
      <Type>3</Type>
      <Code>26320</Code>
      <Quantity>1.000</Quantity>
      <Net>460.80</Net>
      <Clinician>DHA-P-0251405</Clinician>
    </Activity>
    <Activity>
      <ID>2</ID>
      <Start>02/12/2023 00:00</Start>
      <Type>6</Type>
      <Code>D3330</Code>
      <Quantity>1.000</Quantity>
      <Net>310.00</Net>
      <Clinician>DHA-P-0251405</Clinician>
    </Activity>
  </Claim>
  <Claim>
    <ID>TPA002_INS008_02_12_2023_24580_AP0203922</ID>
    <MemberID>62D3-5833-DAA1-D53E</MemberID>
    <PayerID>INS008</PayerID>
    <ProviderID>DHA-F-0045607</ProviderID>
    <EmiratesIDNumber>784-1979-9193542-6</EmiratesIDNumber>
    <Gross>330.00</Gross>
    <PatientShare>20.0</PatientShare>
    <Net>310.00</Net>
    <Encounter>
      <FacilityID>DHA-F-0045607</FacilityID>
      <Type>1</Type>
      <PatientID>AP0203922</PatientID>
      <Start>02/12/2023 00:00</Start>
      <End>02/12/2023 00:00</End>
      <StartType>1</StartType>
      <EndType>1</EndType>
    </Encounter>
    <Diagnosis>
      <Type>Principal</Type>
      <Code>K04.01</Code>
    </Diagnosis>
    <Diagnosis>
      <Type>Secondary</Type>
      <Code>K02.3</Code>
    </Diagnosis>
    <Activity>
      <ID>1</ID>
      <Start>02/12/2023 00:00</Start>
      <Type>6</Type>
      <Code>D3330</Code>
      <Quantity>1.000</Quantity>
      <Net>310.00</Net>
      <Clinician>DHA-P-0251405</Clinician>
      <PriorAuthorizationID>205602203</PriorAuthorizationID>
    </Activity>
  </Claim>
</Claim.Submission>