<?xml version="1.0" encoding="utf-8"?>
<Claim.Submission xmlns:tns="http://www.haad.ae/DataDictionary/CommonTypes" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:noNamespaceSchemaLocation="http://www.haad.ae/DataDictionary/CommonTypes/DataDictionary.xsd">
<Header>
<SenderID>MF7200</SenderID>
<ReceiverID>HAAD</ReceiverID>
<TransactionDate>28/03/2023 20:10</TransactionDate>
<RecordCount>1</RecordCount>
<DispositionFlag>TEST</DispositionFlag>
</Header>
<Claim>
<ID>2</ID>
<MemberID>MF7200#839</MemberID>
<PayerID>SelfPay</PayerID>
<ProviderID>MF7200</ProviderID>
<EmiratesIDNumber>784-1985-0526218-2</EmiratesIDNumber>
<Gross>140.00</Gross>
<PatientShare>140.00</PatientShare>
<Net>0</Net>
<VAT>0.00</VAT>
<Encounter>
<FacilityID>MF7200</FacilityID>
<Type>1</Type>
<PatientID>839</PatientID>
<Start>28/03/2023 10:15</Start>
<End>28/03/2023 10:30</End>
<StartType>1</StartType>
</Encounter>
<Diagnosis>
<Type>Principal</Type>
<Code>K03.6</Code>
</Diagnosis>
<Activity>
<ID>2</ID>
<Start>28/03/2023 10:15</Start>
<Type>6</Type>
<Code>11112</Code>
<Quantity>1.00</Quantity>
<Net>0</Net>
<OrderingClinician>GD37455</OrderingClinician>
<Clinician>GD37455</Clinician>
<PriorAuthorizationID>0</PriorAuthorizationID>
<VAT>0.00</VAT>
<VATPercent>0</VATPercent>
<Observation>
<Type>Universal Dental</Type>
<Code>21</Code>
</Observation>
</Activity>
<Activity>
<ID>2</ID>
<Start>28/03/2023 10:15</Start>
<Type>6</Type>
<Code>11101</Code>
<Quantity>1.00</Quantity>
<Net>0</Net>
<OrderingClinician>GD37455</OrderingClinician>
<Clinician>GD37455</Clinician>
<PriorAuthorizationID>0</PriorAuthorizationID>
<VAT>0.00</VAT>
<VATPercent>0</VATPercent>
<Observation>
<Type>Universal Dental</Type>
<Code>21</Code>
</Observation>
</Activity>
</Claim>
</Claim.Submission>
