<ClaimResponse 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">
  <!-- This would normally be the portion following 'Scen2d-' -->
  <id value="example-ClaimResponse-Scen2d-RB497867223-2023-09-04-1" />
  <contained>
    <MedicationDispense>
      <id value="DISP1" />
      <meta>
        <profile value="https://bpcs.exchange/fhir/StructureDefinition/profile-MedicationDispense" />
      </meta>
      <identifier>
        <value value="5" />
      </identifier>
      <status value="completed" />
      <medication>
        <concept>
          <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>
        </concept>
      </medication>
      <subject>
        <reference value="Patient/7902617849" />
      </subject>
      <whenHandedOver value="2023-09-04" />
    </MedicationDispense>
  </contained>
  <contained>
    <ExplanationOfBenefit>
      <id value="dups" />
      <status value="active" />
      <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="2023-08-16T13:27:37-04:00" />
      <insurer>
        <reference value="Organization/bpcs" />
      </insurer>
      <outcome value="complete" />
      <supportingInfo>
        <sequence value="1" />
        <category>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory" />
            <code value="info" />
          </coding>
        </category>
        <valueReference>
          <reference value="#DISP1" />
        </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-DuplicateVersion">
          <valueUnsignedInt value="1" />
        </extension>
        <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Resource-ReceiptPlan">
          <valueCoding>
            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ProgramPlan" />
            <code value="T" />
          </valueCoding>
        </extension>
        <!--        <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Resource-DeductibleStatus">
          <valueCoding>
            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-DeductibleStatus"/>
            <code value="9"/>
          </valueCoding>
        </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>
        <patientPaid>
          <value value="999.99" />
          <currency value="CAD" />
        </patientPaid>
        <reviewOutcome>
          <decision>
            <coding>
              <system value="http://hl7.org/fhir/claim-decision" />
              <code value="approved" />
            </coding>
          </decision>
        </reviewOutcome>
        <adjudication>
          <category>
            <coding>
              <system value="http://terminology.hl7.org/CodeSystem/adjudication" />
              <code value="benefit" />
            </coding>
          </category>
          <amount>
            <value value="0" />
            <currency value="CAD" />
          </amount>
        </adjudication>
        <adjudication>
          <category>
            <coding>
              <system value="http://terminology.hl7.org/CodeSystem/adjudication" />
              <code value="deductible" />
            </coding>
          </category>
          <amount>
            <value value="999.99" />
            <currency value="CAD" />
          </amount>
        </adjudication>
        <detail>
          <sequence value="1" />
          <productOrService>
            <coding>
              <system value="https://bpcs.exchange/fhir/CodeSystem/cs-CostFee" />
              <code value="drugCost" />
            </coding>
          </productOrService>
          <adjudication>
            <category>
              <coding>
                <system value="http://terminology.hl7.org/CodeSystem/adjudication" />
                <code value="submitted" />
              </coding>
            </category>
            <amount>
              <value value="999.99" />
              <currency value="CAD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="http://terminology.hl7.org/CodeSystem/adjudication" />
                <code value="eligible" />
              </coding>
            </category>
            <amount>
              <value value="100.00" />
              <currency value="CAD" />
            </amount>
          </adjudication>
        </detail>
        <detail>
          <sequence value="2" />
          <productOrService>
            <coding>
              <system value="https://bpcs.exchange/fhir/CodeSystem/cs-CostFee" />
              <code value="pharmacistFee" />
            </coding>
          </productOrService>
          <adjudication>
            <category>
              <coding>
                <system value="http://terminology.hl7.org/CodeSystem/adjudication" />
                <code value="submitted" />
              </coding>
            </category>
            <amount>
              <value value="10" />
              <currency value="CAD" />
            </amount>
          </adjudication>
          <adjudication>
            <category>
              <coding>
                <system value="http://terminology.hl7.org/CodeSystem/adjudication" />
                <code value="eligible" />
              </coding>
            </category>
            <amount>
              <value value="10" />
              <currency value="CAD" />
            </amount>
          </adjudication>
        </detail>
      </item>
    </ExplanationOfBenefit>
  </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="2024-05-02" />
  <!-- Current date -->
  <insurer>
    <reference value="Organization/bpcs" />
  </insurer>
  <outcome value="queued" />
  <item>
    <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Resource-ReceiptPlan">
      <valueCoding>
        <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ProgramPlan" />
        <code value="A" />
      </valueCoding>
    </extension>
    <!-- This will mirror the Claim.item.sequence for the receipt being responded to -->
    <itemSequence value="1" />
    <reviewOutcome>
      <decision>
        <coding>
          <system value="http://hl7.org/fhir/claim-decision" />
          <code value="denied" />
          <!-- currentStatus-->
        </coding>
      </decision>
      <reason>
        <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-DuplicateReceipts">
          <extension url="EOB">
            <valueReference>
              <reference value="#dups" />
            </valueReference>
          </extension>
          <extension url="receipt">
            <valuePositiveInt value="1" />
          </extension>
        </extension>
        <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-AllowedModifier">
          <valueCoding>
            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ClaimModifier" />
            <code value="MQ" />
          </valueCoding>
        </extension>
        <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-AllowedModifier">
          <valueCoding>
            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ClaimModifier" />
            <code value="MR" />
          </valueCoding>
        </extension>
        <coding>
          <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ClaimResponse" />
          <code value="ED" />
        </coding>
      </reason>
    </reviewOutcome>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication" />
          <code value="eligible" />
        </coding>
      </category>
      <amount>
        <value value="0" />
        <currency value="CAD" />
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication" />
          <code value="benefit" />
        </coding>
      </category>
      <amount>
        <value value="0" />
        <currency value="CAD" />
      </amount>
    </adjudication>
  </item>
</ClaimResponse>