-- XML schema extracted from ITU-T H.860 (04/2014)

<!-- Header: Submission identification information -->
<Header>
	<SenderID>insurance1234</SenderID>
	<ReceiverID>hospital5678</ReceiverID>
	<TransactionDate>06/01/2009 15:00</TransactionDate>
	<RecordCount>1</RecordCount>
</Header>
<Claim>
	<IDProvider>hospital1234</IDProvider>
	<IDPayer>insurer4567</IDPayer>
		<Activity>
			<Start>08/01/2013 13:00</Start>
			<Type>3</Type>
			<Code>0031T</Code>
			<Quantity>1</Quantity>
			<Net>6000</Net>
			<ClinicianID>clinician1234</ClinicianID>
			<PriorAuthorizationID>1235</PriorAuthorizationID>
			<Gross>6000</Gross>
			<PatientShare>500</PatientShare>
			<PaymentAmount>5500</PaymentAmount>
		</Activity>
</Claim>