<?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>Docmate</SenderID>
    <ReceiverID>TPA004</ReceiverID>
    <TransactionDate>18/09/2024 17:19</TransactionDate>
    <RecordCount>1</RecordCount>
    <DispositionFlag>TEST</DispositionFlag>
  </Header>
  <Claim>
    <ID>TPA004_INS027_18_09_2024_24754_100030</ID>
    <MemberID>werer3355</MemberID>
    <PayerID>INS027</PayerID>
    <ProviderID>Docmate</ProviderID>
    <EmiratesIDNumber>111-1111-1111111-1</EmiratesIDNumber>
    <Gross>1024.00</Gross>
    <PatientShare>102.400</PatientShare>
    <Net>921.60</Net>
    <Encounter>
      <FacilityID>Docmate</FacilityID>
      <Type>1</Type>
      <PatientID>100030</PatientID>
      <Start>18/09/2024 00:00</Start>
      <End>18/09/2024 00:00</End>
      <StartType>1</StartType>
      <EndType>1</EndType>
    </Encounter>
    <Diagnosis>
      <Type>Principal</Type>
      <Code>K02.3</Code>
    </Diagnosis>
    <Activity>
      <ID>1</ID>
      <Start>18/09/2024 00:00</Start>
      <Type>6</Type>
      <Code>D3330</Code>
      <Quantity>1.000</Quantity>
      <Net>460.80</Net>
      <Clinician>DHA-P-0251405</Clinician>
      <PriorAuthorizationID>service 1</PriorAuthorizationID>
      <Observation>
        <Type>Universal Dental</Type>
        <Code>Tooth No 2</Code>
        <Value>2</Value>
        <ValueType>ToothNo 2</ValueType>
      </Observation>
      <Observation>
        <Type>Universal Dental</Type>
        <Code>ToothNo</Code>
        <Value>3</Value>
        <ValueType>Tooth No</ValueType>
      </Observation>
    </Activity>
    <Activity>
      <ID>2</ID>
      <Start>18/09/2024 00:00</Start>
      <Type>6</Type>
      <Code>D3330</Code>
      <Quantity>1.000</Quantity>
      <Net>460.80</Net>
      <Clinician>DHA-P-0251405</Clinician>
      <PriorAuthorizationID>service 2</PriorAuthorizationID>
      <Observation>
        <Type>Universal Dental</Type>
        <Code>Tooth No 2</Code>
        <Value>2</Value>
        <ValueType>ToothNo 2</ValueType>
      </Observation>
      <Observation>
        <Type>Universal Dental</Type>
        <Code>ToothNo</Code>
        <Value>3</Value>
        <ValueType>Tooth No</ValueType>
      </Observation>
    </Activity>
  </Claim>
</Claim.Submission>