{
  "resourceType": "ClaimResponse",
  "id": "example-ClaimResponse-Scen2d-RB497867223-2023-09-04-1",
  "contained": [
    {
      "resourceType": "MedicationDispense",
      "id": "DISP1",
      "meta": {
        "profile": [
          "https://bpcs.exchange/fhir/StructureDefinition/profile-MedicationDispense"
        ]
      },
      "identifier": [
        {
          "value": "5"
        }
      ],
      "status": "completed",
      "medication": {
        "concept": {
          "coding": [
            {
              "system": "http://hl7.org/fhir/NamingSystem/ca-hc-din",
              "code": "2370816",
              "display": "Victrelis"
            },
            {
              "system": "http://terminology.hl7.org/CodeSystem/hc-CCDD",
              "display": "BOCEPREVIR"
            }
          ]
        }
      },
      "subject": {
        "reference": "Patient/7902617849"
      },
      "whenHandedOver": "2023-09-04"
    },
    {
      "resourceType": "ExplanationOfBenefit",
      "id": "dups",
      "status": "active",
      "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": "2023-08-16T17:27:37+00:00",
      "insurer": {
        "reference": "Organization/bpcs"
      },
      "outcome": "complete",
      "supportingInfo": [
        {
          "sequence": 1,
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
                "code": "info"
              }
            ]
          },
          "valueReference": {
            "reference": "#DISP1"
          }
        }
      ],
      "item": [
        {
          "extension": [
            {
              "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-ReceiptPatient",
              "valueReference": {
                "reference": "Patient/7902617849"
              }
            },
            {
              "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-DuplicateVersion",
              "valueUnsignedInt": 1
            },
            {
              "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-Resource-ReceiptPlan",
              "valueCoding": {
                "system": "https://bpcs.exchange/fhir/CodeSystem/cs-ProgramPlan",
                "code": "T"
              }
            }
          ],
          "sequence": 1,
          "informationSequence": [
            1
          ],
          "productOrService": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/NamingSystem/ca-hc-din",
                "code": "2370816",
                "display": "Victrelis"
              },
              {
                "system": "http://terminology.hl7.org/CodeSystem/hc-CCDD",
                "display": "BOCEPREVIR"
              }
            ]
          },
          "patientPaid": {
            "value": 999.99,
            "currency": "CAD"
          },
          "reviewOutcome": {
            "decision": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/claim-decision",
                  "code": "approved"
                }
              ]
            }
          },
          "adjudication": [
            {
              "category": {
                "coding": [
                  {
                    "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                    "code": "benefit"
                  }
                ]
              },
              "amount": {
                "value": 0,
                "currency": "CAD"
              }
            },
            {
              "category": {
                "coding": [
                  {
                    "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                    "code": "deductible"
                  }
                ]
              },
              "amount": {
                "value": 999.99,
                "currency": "CAD"
              }
            }
          ],
          "detail": [
            {
              "sequence": 1,
              "productOrService": {
                "coding": [
                  {
                    "system": "https://bpcs.exchange/fhir/CodeSystem/cs-CostFee",
                    "code": "drugCost"
                  }
                ]
              },
              "adjudication": [
                {
                  "category": {
                    "coding": [
                      {
                        "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                        "code": "submitted"
                      }
                    ]
                  },
                  "amount": {
                    "value": 999.99,
                    "currency": "CAD"
                  }
                },
                {
                  "category": {
                    "coding": [
                      {
                        "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                        "code": "eligible"
                      }
                    ]
                  },
                  "amount": {
                    "value": 100.0,
                    "currency": "CAD"
                  }
                }
              ]
            },
            {
              "sequence": 2,
              "productOrService": {
                "coding": [
                  {
                    "system": "https://bpcs.exchange/fhir/CodeSystem/cs-CostFee",
                    "code": "pharmacistFee"
                  }
                ]
              },
              "adjudication": [
                {
                  "category": {
                    "coding": [
                      {
                        "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                        "code": "submitted"
                      }
                    ]
                  },
                  "amount": {
                    "value": 10,
                    "currency": "CAD"
                  }
                },
                {
                  "category": {
                    "coding": [
                      {
                        "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                        "code": "eligible"
                      }
                    ]
                  },
                  "amount": {
                    "value": 10,
                    "currency": "CAD"
                  }
                }
              ]
            }
          ]
        }
      ]
    }
  ],
  "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": "queued",
  "item": [
    {
      "extension": [
        {
          "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-Resource-ReceiptPlan",
          "valueCoding": {
            "system": "https://bpcs.exchange/fhir/CodeSystem/cs-ProgramPlan",
            "code": "A"
          }
        }
      ],
      "itemSequence": 1,
      "reviewOutcome": {
        "decision": {
          "coding": [
            {
              "system": "http://hl7.org/fhir/claim-decision",
              "code": "denied"
            }
          ]
        },
        "reason": [
          {
            "extension": [
              {
                "extension": [
                  {
                    "url": "EOB",
                    "valueReference": {
                      "reference": "#dups"
                    }
                  },
                  {
                    "url": "receipt",
                    "valuePositiveInt": 1
                  }
                ],
                "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-DuplicateReceipts"
              },
              {
                "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-AllowedModifier",
                "valueCoding": {
                  "system": "https://bpcs.exchange/fhir/CodeSystem/cs-ClaimModifier",
                  "code": "MQ"
                }
              },
              {
                "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-AllowedModifier",
                "valueCoding": {
                  "system": "https://bpcs.exchange/fhir/CodeSystem/cs-ClaimModifier",
                  "code": "MR"
                }
              }
            ],
            "coding": [
              {
                "system": "https://bpcs.exchange/fhir/CodeSystem/cs-ClaimResponse",
                "code": "ED"
              }
            ]
          }
        ]
      },
      "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"
          }
        }
      ]
    }
  ]
}