{
  "resourceType": "ClaimResponse",
  "id": "example-ClaimResponse-Scen1d-RB497867223-2023-01-01-35",
  "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": "2024-05-02",
  "insurer": {
    "reference": "Organization/bpcs"
  },
  "outcome": "complete",
  "item": [
    {
      "extension": [
        {
          "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-Resource-ReceiptPlan",
          "valueCoding": {
            "system": "https://bpcs.exchange/fhir/CodeSystem/cs-ProgramPlan",
            "code": "T"
          }
        }
      ],
      "itemSequence": 1,
      "reviewOutcome": {
        "decision": {
          "coding": [
            {
              "system": "http://hl7.org/fhir/claim-decision",
              "code": "denied"
            }
          ]
        }
      },
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "eligible"
              }
            ]
          },
          "amount": {
            "value": 0,
            "currency": "CAD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "value": 0,
            "currency": "CAD"
          }
        }
      ]
    },
    {
      "extension": [
        {
          "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-Resource-ReceiptPlan",
          "valueCoding": {
            "system": "https://bpcs.exchange/fhir/CodeSystem/cs-ProgramPlan",
            "code": "T"
          }
        }
      ],
      "itemSequence": 2,
      "reviewOutcome": {
        "decision": {
          "coding": [
            {
              "system": "http://hl7.org/fhir/claim-decision",
              "code": "denied"
            }
          ]
        }
      },
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "eligible"
              }
            ]
          },
          "amount": {
            "value": 0,
            "currency": "CAD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "value": 0,
            "currency": "CAD"
          }
        }
      ]
    }
  ]
}