{
  "resourceType": "Claim",
  "id": "example-Claim-submit-Scen3e-RB497867223-2023-08-01-2",
  "contained": [
    {
      "resourceType": "MedicationDispense",
      "id": "dispense1",
      "identifier": [
        {
          "value": "000000002"
        }
      ],
      "status": "completed",
      "medication": {
        "concept": {
          "coding": [
            {
              "system": "http://ehealthontario.ca/fhir/NamingSystem/ca-on-provincial-pin",
              "code": "22222222",
              "display": "TABS DRUG"
            }
          ]
        }
      },
      "subject": {
        "reference": "Patient/7902617849"
      },
      "quantity": {
        "value": 55.0
      },
      "whenHandedOver": "2023-08-01"
    }
  ],
  "status": "draft",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "pharmacy"
      }
    ]
  },
  "use": "claim",
  "patient": {
    "extension": [
      {
        "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-Resource-Subject",
        "valueReference": {
          "reference": "Group/RB497867223"
        }
      }
    ],
    "display": "Family RB497867223"
  },
  "created": "2022-08-03",
  "insurer": {
    "reference": "Organization/bpcs"
  },
  "supportingInfo": [
    {
      "sequence": 1,
      "category": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
            "code": "info"
          }
        ]
      },
      "valueReference": {
        "reference": "#dispense1"
      }
    }
  ],
  "item": [
    {
      "extension": [
        {
          "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-ReceiptPatient",
          "valueReference": {
            "reference": "Patient/7902617849"
          }
        },
        {
          "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-ReceivedDate",
          "valueDate": "2023-08-01"
        },
        {
          "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-Resource-Mode",
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationMode",
            "code": "MAILWRIT",
            "display": "mail"
          }
        },
        {
          "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-OverriddenReasons",
          "valueCoding": {
            "system": "https://bpcs.exchange/fhir/CodeSystem/cs-ClaimResponse",
            "code": "M8"
          }
        },
        {
          "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-OverriddenReasons",
          "valueCoding": {
            "system": "https://bpcs.exchange/fhir/CodeSystem/cs-ClaimResponse",
            "code": "EG"
          }
        },
        {
          "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-OverrideNet",
          "valueMoney": {
            "value": 5,
            "currency": "CAD"
          }
        },
        {
          "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-OverrideReason",
          "valueString": "test override amt"
        }
      ],
      "sequence": 1,
      "informationSequence": [
        1
      ],
      "productOrService": {
        "coding": [
          {
            "system": "http://ehealthontario.ca/fhir/NamingSystem/ca-on-provincial-pin",
            "code": "9853359",
            "display": "TABS DRUG"
          },
          {
            "system": "http://terminology.hl7.org/CodeSystem/hc-CCDD",
            "display": "EXTEMPORANEOUS MIXTURE"
          }
        ],
        "text": "TABS DRUG"
      },
      "modifier": [
        {
          "coding": [
            {
              "system": "https://bpcs.exchange/fhir/CodeSystem/cs-ClaimModifier",
              "code": "_PI-1"
            }
          ]
        },
        {
          "coding": [
            {
              "system": "https://bpcs.exchange/fhir/CodeSystem/cs-ClaimModifier",
              "code": "M8-1"
            }
          ]
        }
      ],
      "servicedDate": "2023-09-04",
      "patientPaid": {
        "value": 10.0,
        "currency": "CAD"
      },
      "quantity": {
        "value": 55.0
      },
      "net": {
        "value": 10.0,
        "currency": "CAD"
      },
      "detail": [
        {
          "sequence": 1,
          "productOrService": {
            "coding": [
              {
                "system": "https://bpcs.exchange/fhir/CodeSystem/cs-CostFee",
                "code": "drugCost"
              }
            ]
          },
          "net": {
            "value": 5.0,
            "currency": "CAD"
          }
        },
        {
          "sequence": 2,
          "productOrService": {
            "coding": [
              {
                "system": "https://bpcs.exchange/fhir/CodeSystem/cs-CostFee",
                "code": "pharmacistFee"
              }
            ]
          },
          "net": {
            "value": 5.0,
            "currency": "CAD"
          }
        }
      ]
    }
  ]
}