<Claim xmlns="http://hl7.org/fhir" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://hl7.org/fhir ../../input-cache/schemas/R5/fhir-single.xsd">
  <!-- The real id would be the portion after 'Scen2g-' -->
  <id value="example-Claim-submit-Scen2g-RB497867223-2023-09-04-1" />
  <contained>
    <MedicationDispense>
      <id value="dispense1" />
      <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-MedicationDispense-PrescriberLicense">
        <valueCoding>
          <system value="https://bpcs.exchange/fhir/CodeSystem/cs-PrescriberLicense" />
          <code value="44" />
          <display value="College of Nurses of Ontario" />
        </valueCoding>
      </extension>
      <identifier>
        <value value="1" />
      </identifier>
      <status value="completed" />
      <medication>
        <concept>
          <coding>
            <system value="http://hl7.org/fhir/NamingSystem/ca-hc-din" />
            <code value="2370816" />
          </coding>
        </concept>
      </medication>
      <subject>
        <reference value="Patient/7902617849" />
      </subject>
      <quantity>
        <value value="4.0" />
      </quantity>
      <whenHandedOver value="2023-09-04" />
    </MedicationDispense>
  </contained>
  <status value="draft" />
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type" />
      <code value="pharmacy" />
    </coding>
  </type>
  <use value="claim" />
  <patient>
    <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Resource-Subject">
      <valueReference>
        <reference value="Group/RB497867223" />
      </valueReference>
    </extension>
    <display value="Family RB497867223" />
  </patient>
  <created value="2022-08-03" />
  <insurer>
    <reference value="Organization/bpcs" />
  </insurer>
  <supportingInfo>
    <sequence value="1" />
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory" />
        <code value="info" />
      </coding>
    </category>
    <valueReference>
      <reference value="#dispense1" />
    </valueReference>
  </supportingInfo>
  <item>
    <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-ReceiptPatient">
      <valueReference>
        <reference value="Patient/7902617849" />
      </valueReference>
    </extension>
    <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-ReceivedDate">
      <valueDate value="2023-09-04" />
    </extension>
    <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Resource-Mode">
      <valueCoding>
        <system value="http://terminology.hl7.org/CodeSystem/v3-ParticipationMode" />
        <code value="MAILWRIT" />
        <display value="mail" />
      </valueCoding>
    </extension>
    <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-OverriddenReasons">
      <valueCoding>
        <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ClaimResponse" />
        <code value="ED" />
      </valueCoding>
    </extension>
    <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-OverrideNet">
      <valueMoney>
        <value value="0" />
        <currency value="CAD" />
      </valueMoney>
    </extension>
    <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-OverrideReason">
      <valueString value="TEST" />
    </extension>
    <sequence value="1" />
    <informationSequence value="1" />
    <productOrService>
      <coding>
        <system value="http://hl7.org/fhir/NamingSystem/ca-hc-din" />
        <code value="2370816" />
        <display value="Victrelis" />
      </coding>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/hc-CCDD" />
        <display value="BOCEPREVIR" />
      </coding>
    </productOrService>
    <modifier>
      <coding>
        <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ClaimModifier" />
        <code value="_PI-1" />
      </coding>
    </modifier>
    <modifier>
      <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-DuplicateVersion">
        <valueUnsignedInt value="1" />
      </extension>
      <coding>
        <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ClaimModifier" />
        <code value="ACPT" />
      </coding>
    </modifier>
    <modifier>
      <coding>
        <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ClaimResponse" />
        <code value="EF" />
      </coding>
    </modifier>
    <servicedDate value="2023-09-04" />
    <patientPaid>
      <value value="4.0" />
      <currency value="CAD" />
    </patientPaid>
    <quantity>
      <value value="4.0" />
    </quantity>
    <net>
      <value value="4.0" />
      <currency value="CAD" />
    </net>
    <detail>
      <sequence value="1" />
      <productOrService>
        <coding>
          <system value="https://bpcs.exchange/fhir/CodeSystem/cs-CostFee" />
          <code value="drugCost" />
        </coding>
      </productOrService>
      <net>
        <value value="4.0" />
        <currency value="CAD" />
      </net>
    </detail>
    <detail>
      <sequence value="2" />
      <productOrService>
        <coding>
          <system value="https://bpcs.exchange/fhir/CodeSystem/cs-CostFee" />
          <code value="pharmacistFee" />
        </coding>
      </productOrService>
      <net>
        <value value="0.0" />
        <currency value="CAD" />
      </net>
    </detail>
  </item>
  <!--
      <odbNum>7902617849</odbNum>
      <currentStatus>H</currentStatus>
-->
</Claim>