<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">
  <!-- id will typically be application num or odbNum, followed by received date, followed by sequence -->
  <id value="example-Claim-update" />
  <contained>
    <MedicationDispense>
      <id value="dispense1" />
      <identifier>
        <value value="000000001" />
      </identifier>
      <status value="completed" />
      <medication>
        <concept>
          <coding>
            <system value="http://hl7.org/fhir/NamingSystem/ca-hc-din" />
            <code value="00023450" />
          </coding>
        </concept>
      </medication>
      <subject>
        <!-- This would normally be the odbNum -->
        <reference value="Patient/example-Patient" />
      </subject>
      <quantity>
        <value value="5.0" />
      </quantity>
      <whenHandedOver value="2023-08-15" />
    </MedicationDispense>
  </contained>
  <contained>
    <MedicationDispense>
      <id value="dispense2" />
      <identifier>
        <value value="000000002" />
      </identifier>
      <status value="completed" />
      <medication>
        <concept>
          <coding>
            <system value="http://hl7.org/fhir/NamingSystem/ca-hc-din" />
            <code value="02357658" />
          </coding>
        </concept>
      </medication>
      <subject>
        <!-- This would normally be the odbNum -->
        <reference value="Patient/example-Patient" />
      </subject>
      <quantity>
        <value value="5.0" />
      </quantity>
      <whenHandedOver value="2023-08-15" />
    </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>
        <!-- This would normally be the application number -->
        <reference value="Group/example-Group" />
      </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>
  <supportingInfo>
    <sequence value="2" />
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory" />
        <code value="info" />
      </coding>
    </category>
    <valueReference>
      <reference value="#dispense2" />
    </valueReference>
  </supportingInfo>
  <item>
    <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-ReceiptPatient">
      <valueReference>
        <!-- This would normally be the odbNum -->
        <reference value="Patient/example-Patient" />
      </valueReference>
    </extension>
    <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-ReceivedDate">
      <valueDate value="2023-08-15" />
    </extension>
    <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Resource-Mode">
      <valueCoding>
        <system value="http://terminology.hl7.org/CodeSystem/v3-ParticipationMode" />
        <code value="ELECTRONIC" />
        <display value="electronic data" />
      </valueCoding>
    </extension>
    <sequence value="1" />
    <informationSequence value="1" />
    <productOrService>
      <coding>
        <system value="http://hl7.org/fhir/NamingSystem/ca-hc-din" />
        <code value="00023450" />
        <display value="Dilantin-125 Suspension" />
      </coding>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/hc-CCDD" />
        <display value="PHENYTOIN (DIPHENYLHYDANTOIN)" />
      </coding>
    </productOrService>
    <servicedDate value="2023-08-15" />
    <patientPaid>
      <value value="5.0" />
      <currency value="CAD" />
    </patientPaid>
    <quantity>
      <value value="5.0" />
    </quantity>
    <net>
      <value value="5.0" />
      <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="5.0" />
        <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>
  <item>
    <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-ReceiptPatient">
      <valueReference>
        <!-- This would normally be the odbNum -->
        <reference value="Patient/example-Patient" />
      </valueReference>
    </extension>
    <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-ReceivedDate">
      <valueDate value="2023-08-15" />
    </extension>
    <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Resource-Mode">
      <valueCoding>
        <system value="http://terminology.hl7.org/CodeSystem/v3-ParticipationMode" />
        <code value="ELECTRONIC" />
        <display value="electronic data" />
      </valueCoding>
    </extension>
    <sequence value="2" />
    <informationSequence value="2" />
    <productOrService>
      <coding>
        <system value="http://hl7.org/fhir/NamingSystem/ca-hc-din" />
        <code value="02357658" />
        <display value="Vimpat" />
      </coding>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/hc-CCDD" />
        <display value="LACOSAMIDE" />
      </coding>
    </productOrService>
    <servicedDate value="2023-08-15" />
    <patientPaid>
      <value value="6.0" />
      <currency value="CAD" />
    </patientPaid>
    <quantity>
      <value value="5.0" />
    </quantity>
    <net>
      <value value="6.0" />
      <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="6.0" />
        <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>
  <!--
    <ca.ontario.health.hns.web.dto.cm.ReceiptDTO>
      <adjRecpntPaidAmt>5.0</adjRecpntPaidAmt>
      <assessFormInd>Y</assessFormInd>
    </ca.ontario.health.hns.web.dto.cm.ReceiptDTO>
    <ca.ontario.health.hns.web.dto.cm.ReceiptDTO>
      <adjRecpntPaidAmt>6.0</adjRecpntPaidAmt>
      <assessFormInd>Y</assessFormInd>
    </ca.ontario.health.hns.web.dto.cm.ReceiptDTO>
-->
</Claim>