<?xml version="1.0" encoding="UTF-8" ?>
<!--Sample XML file generated by XMLSpy v2006 rel. 3 sp1 (http://www.altova.com)-->
<CIMOR_RA xmlns="http://tempuri.org/CIMOR_RA.xsd" xmlns:msdata="urn:schemas-microsoft-com:xml-msdata"
	xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://tempuri.org/CIMOR_RA.xsd
C:\MORELE~1\VISUAL~1\CIMORX~1\CIMORX~1\CIMOR_RA.xsd">
	<Transaction>
		<Provider_Number>876176303</Provider_Number>
		<Provider_Name>Preferred Family Healthcare</Provider_Name>
		<National_Provider_Number>123456789-</National_Provider_Number>
		<Facility_Code>153</Facility_Code>
		<Production_Date>yyyy-7-21T09:30:47.0Z</Production_Date>
		<Charged_Amount>169219.29</Charged_Amount>
		<Billed_Amount>129714.93</Billed_Amount>
		<Paid_Amount>93126.51</Paid_Amount>
		<Check_Number>##############</Check_Number>
		<Provider_Level_Adjustments>
			<Provider_Number>876176303</Provider_Number>
			<National_Provider_Number>123456789-</National_Provider_Number>
			<Adjustment_Reason_Code>WO</Adjustment_Reason_Code>
			<Adjustment_Identifier>SYS AR DCN ######## DOS mmddyy</Adjustment_Identifier>
			<Medicaid_Adjustment_Amount>17.54</Medicaid_Adjustment_Amount>
			<DMH_Adjustment_Amount>23.54</DMH_Adjustment_Amount>
		</Provider_Level_Adjustments>
		<Claim>
			<Provider_Number>876176303</Provider_Number>
			<National_Provider_Number>900123456</National_Provider_Number>
			<Claim_ID>xx###-5303721</Claim_ID>
			<DMH_ID>#######</DMH_ID>
			<ICN>#############</ICN>
			<DCN>########</DCN>
			<Start_Date>yyyy-mm-dd</Start_Date>
			<End_Date>yyyy-mm-dd</End_Date>
			<Last_Name>xxxxxxx</Last_Name>
			<First_Name>xxxxxxxxxx</First_Name>
			<Charged_Amount>48.40</Charged_Amount>
			<Billed_Amount>41.60</Billed_Amount>
			<Mediciad_Paid_Amount>29.97</Mediciad_Paid_Amount>
			<DMH_Paid_Amount>41.60</DMH_Paid_Amount>
			<Service>
				<Claim_ID>xx###-5303721</Claim_ID>
				<Sequence_Number>xx###-5303721-1</Sequence_Number>
				<ICN>#############</ICN>
				<DCN>########</DCN>
				<Start_Date>yyyy-mm-dd</Start_Date>
				<End_Date>yyyy-mm-dd</End_Date>
				<Last_Name>xxxxx</Last_Name>
				<First_Name>xxxxxxx</First_Name>
				<Procedure_Code>H2017</Procedure_Code>
				<Modifier_1>PR</Modifier_1>
				<Modifier_2></Modifier_2>
				<Units_Billed>2</Units_Billed>
				<Charged_Amount>24.20</Charged_Amount>
				<Billed_Amount>20.80</Billed_Amount>
				<Medicaid_Paid_Amount>14.98</Medicaid_Paid_Amount>
				<DMH_Paid_Amount>20.80</DMH_Paid_Amount>
				<Service_Category>CPS-ADULT-C</Service_Category>
				<Payer_Plan>?</Payer_Plan>
				<Adjustment>
					<Claim_ID>xx###-5303721</Claim_ID>
					<Sequence_Number>xx###-5303721-1</Sequence_Number>
					<Group_Code>CO</Group_Code>
					<Reason_Code>45</Reason_Code>
					<Adjustment_Amount>3.14</Adjustment_Amount>
				</Adjustment>
				<Adjustment>
					<Claim_ID>xx###-5303721</Claim_ID>
					<Sequence_Number>xx###-5303721-1</Sequence_Number>
					<Group_Code>PR</Group_Code>
					<Reason_Code>177</Reason_Code>
					<Adjustment_Amount>2.14</Adjustment_Amount>
				</Adjustment>
				<Remark>
					<Claim_ID>xx###-5303721</Claim_ID>
					<Sequence_Number>xx###-5303721-1</Sequence_Number>
					<Remark_Qualifier>HE</Remark_Qualifier>
					<Remark_Code>N59</Remark_Code>
				</Remark>
			</Service>
		</Claim>
		<Claim>
			<Provider_Number>876176303</Provider_Number>
			<National_Provider_Number>900123456</National_Provider_Number>
			<Claim_ID>xx###-5303722</Claim_ID>
			<DMH_ID>#######</DMH_ID>
			<ICN>#############</ICN>
			<DCN>########</DCN>
			<Start_Date>yyyy-mm-dd</Start_Date>
			<End_Date>yyyy-mm-dd</End_Date>
			<Last_Name>xxxx</Last_Name>
			<First_Name>xxxxxxxx</First_Name>
			<Charged_Amount>48.40</Charged_Amount>
			<Billed_Amount>41.60</Billed_Amount>
			<Mediciad_Paid_Amount>29.97</Mediciad_Paid_Amount>
			<DMH_Paid_Amount>41.60</DMH_Paid_Amount>
			<Service>
				<Claim_ID>xx###-5303722</Claim_ID>
				<Sequence_Number>xx###-5303722-1</Sequence_Number>
				<ICN>xxxxxxxxxxxxx</ICN>
				<DCN>########</DCN>
				<Start_Date>yyyy-mm-dd</Start_Date>
				<End_Date>yyyy-mm-dd</End_Date>
				<Last_Name>xxxx</Last_Name>
				<First_Name>xxxxxxxx</First_Name>
				<Procedure_Code>H2017</Procedure_Code>
				<Modifier_1>PR</Modifier_1>
				<Modifier_2></Modifier_2>
				<Units_Billed>2</Units_Billed>
				<Charged_Amount>24.20</Charged_Amount>
				<Billed_Amount>20.80</Billed_Amount>
				<Medicaid_Paid_Amount>14.98</Medicaid_Paid_Amount>
				<DMH_Paid_Amount>20.80</DMH_Paid_Amount>
				<Service_Category>CPS-ADULT-C</Service_Category>
				<Payer_Plan>?</Payer_Plan>
				<Adjustment>
					<Claim_ID>xx###-5303722</Claim_ID>
					<Sequence_Number>xx###-5303722-1</Sequence_Number>
					<Group_Code>CO</Group_Code>
					<Reason_Code>45</Reason_Code>
					<Adjustment_Amount>3.14</Adjustment_Amount>
				</Adjustment>
				<Adjustment>
					<Claim_ID>xx###-5303722</Claim_ID>
					<Sequence_Number>xx###-5303722-1</Sequence_Number>
					<Group_Code>PR</Group_Code>
					<Reason_Code>177</Reason_Code>
					<Adjustment_Amount>2.14</Adjustment_Amount>
				</Adjustment>
				<Remark>
					<Claim_ID>xx###-5303722</Claim_ID>
					<Sequence_Number>xx###-5303722-1</Sequence_Number>
					<Remark_Qualifier>HE</Remark_Qualifier>
					<Remark_Code>N59</Remark_Code>
				</Remark>
			</Service>
			<Service>
				<Claim_ID>xx###-5303722</Claim_ID>
				<Sequence_Number>xx###-5303722-2</Sequence_Number>
				<ICN>#############</ICN>
				<DCN>########</DCN>
				<Start_Date>yyyy-mm-dd</Start_Date>
				<End_Date>yyyy-mm-dd</End_Date>
				<Last_Name>xxxxx</Last_Name>
				<First_Name>xxxxxxxx</First_Name>
				<Procedure_Code>H2017</Procedure_Code>
				<Modifier_1>PR</Modifier_1>
				<Modifier_2></Modifier_2>
				<Units_Billed>2</Units_Billed>
				<Charged_Amount>24.20</Charged_Amount>
				<Billed_Amount>20.80</Billed_Amount>
				<Medicaid_Paid_Amount>14.98</Medicaid_Paid_Amount>
				<DMH_Paid_Amount>20.80</DMH_Paid_Amount>
				<Service_Category>CPS-ADULT-C</Service_Category>
				<Payer_Plan>?</Payer_Plan>
				<Adjustment>
					<Claim_ID>xx###-5303722</Claim_ID>
					<Sequence_Number>xx###-5303722-2</Sequence_Number>
					<Group_Code>CO</Group_Code>
					<Reason_Code>45</Reason_Code>
					<Adjustment_Amount>3.14</Adjustment_Amount>
				</Adjustment>
				<Adjustment>
					<Claim_ID>xx###-5303722</Claim_ID>
					<Sequence_Number>xx###-5303722-2</Sequence_Number>
					<Group_Code>PR</Group_Code>
					<Reason_Code>177</Reason_Code>
					<Adjustment_Amount>2.14</Adjustment_Amount>
				</Adjustment>
				<Remark>
					<Claim_ID>xx###-5303722</Claim_ID>
					<Sequence_Number>xx###-5303722-2</Sequence_Number>
					<Remark_Qualifier>HE</Remark_Qualifier>
					<Remark_Code>N59</Remark_Code>
				</Remark>
			</Service>
		</Claim>
	</Transaction>
</CIMOR_RA>
