<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">
  <!--    On a create, no id will be provided.  One is included here for publishing reasons only    -->
  <id value="example-ClaimResponse" />
  <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="23450" />
            <display value="Dilantin-125 Suspension" />
          </coding>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/hc-CCDD" />
            <display value="PHENYTOIN (DIPHENYLHYDANTOIN)" />
          </coding>
        </concept>
      </medication>
      <subject>
        <reference value="Patient/example-Patient" />
        <!-- This would normally be the odbNum from the original claim -->
      </subject>
      <whenHandedOver value="2022-06-25" />
    </MedicationDispense>
  </contained>
  <contained>
    <MedicationDispense>
      <id value="DISP2" />
      <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="23450" />
            <display value="Dilantin-125 Suspension" />
          </coding>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/hc-CCDD" />
            <display value="PHENYTOIN (DIPHENYLHYDANTOIN)" />
          </coding>
        </concept>
      </medication>
      <subject>
        <reference value="Patient/example-Patient" />
        <!-- This would normally be the odbNum from the original claim -->
      </subject>
      <whenHandedOver value="2022-06-13" />
    </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>
            <!-- This would normally be the application number -->
            <reference value="Group/example-Group" />
          </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>
      <supportingInfo>
        <sequence value="2" />
        <category>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory" />
            <code value="info" />
          </coding>
        </category>
        <valueReference>
          <reference value="#DISP2" />
        </valueReference>
      </supportingInfo>
      <item>
        <!--
  <duplicateClaims>
    <ca.ontario.health.hns.web.dto.cm.DuplicateClaimDTO>
      <outputTotal>100.0</outputTotal>
*      <transCd>01</transCd>
*      <maxRecipReimbAmt>0.0</maxRecipReimbAmt>
*      <ovrpdlogExistFlag>false</ovrpdlogExistFlag>
*      <exactMatchFlag>false</exactMatchFlag>
    </ca.ontario.health.hns.web.dto.cm.DuplicateClaimDTO>
-->
        <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-ReceiptPatient">
          <valueReference>
            <reference value="Patient/example-Patient" />
            <!-- This will normally be the odbNum of the patient from the original claim -->
          </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="1" />
          </valueCoding>
        </extension>
        <sequence value="1" />
        <informationSequence value="1" />
        <productOrService>
          <coding>
            <system value="http://hl7.org/fhir/NamingSystem/ca-hc-din" />
            <code value="23450" />
            <display value="Dilantin-125 Suspension" />
          </coding>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/hc-CCDD" />
            <display value="PHENYTOIN (DIPHENYLHYDANTOIN)" />
          </coding>
        </productOrService>
        <modifier>
          <coding>
            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-MedicalReason" />
            <code value="25" />
          </coding>
        </modifier>
        <patientPaid>
          <value value="999" />
          <currency value="CAD" />
        </patientPaid>
        <reviewOutcome>
          <decision>
            <coding>
              <system value="http://hl7.org/fhir/claim-decision" />
              <code value="denied" />
            </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" />
            <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" />
              <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" />
              <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>
      <item>
        <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-ReceiptPatient">
          <valueReference>
            <reference value="Patient/example-Patient" />
            <!-- This will normally be the odbNum of the patient from the original claim -->
          </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>
        <sequence value="2" />
        <informationSequence value="2" />
        <productOrService>
          <coding>
            <system value="http://hl7.org/fhir/NamingSystem/ca-hc-din" />
            <code value="23450" />
            <display value="Dilantin-125 Suspension" />
          </coding>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/hc-CCDD" />
            <display value="PHENYTOIN (DIPHENYLHYDANTOIN)" />
          </coding>
        </productOrService>
        <modifier>
          <coding>
            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-MedicalReason" />
            <code value="25" />
          </coding>
        </modifier>
        <patientPaid>
          <value value="999" />
          <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" />
            <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" />
              <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" />
              <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>
        <!-- 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>
  <request>
    <!-- This will echo the Claim.id as it was on the inbound request (application num or odbNum, followed by submitted date, followed by sequence) -->
    <reference value="Claim/example-Claim-submit" />
  </request>
  <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="T" />
      </valueCoding>
    </extension>
    <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-PresetModifier">
      <valueCoding>
        <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ClaimModifier" />
        <code value="MQ" />
      </valueCoding>
    </extension>
    <!-- This will mirror the Claim.item.sequence for the receipt being responded to -->
    <itemSequence value="1" />
    <reviewOutcome>
      <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-Info">
        <valueCodeableConcept>
          <coding>
            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ClaimResponseInfo" />
            <code value="NOSUB" />
          </coding>
        </valueCodeableConcept>
      </extension>
      <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 url="receipt">
            <valuePositiveInt value="2" />
          </extension>
        </extension>
        <coding>
          <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ClaimResponse" />
          <code value="EE.R" />
        </coding>
      </reason>
      <reason>
        <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-AllowedModifier">
          <valueCoding>
            <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-PreExistingCondition">
              <valueBoolean value="true" />
            </extension>
            <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-AllowedModifierDefault">
              <valueBoolean value="true" />
            </extension>
            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-MedicalReason" />
            <code value="483" />
          </valueCoding>
        </extension>
        <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-AllowedModifier">
          <valueCoding>
            <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-PreExistingCondition">
              <valueBoolean value="true" />
            </extension>
            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-MedicalReason" />
            <code value="482" />
          </valueCoding>
        </extension>
        <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-AllowedModifier">
          <valueCoding>
            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-MedicalReason" />
            <code value="484" />
          </valueCoding>
        </extension>
        <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ClaimResponse-AllowedModifier">
          <valueCoding>
            <system value="https://bpcs.exchange/fhir/CodeSystem/cs-MedicalReason" />
            <code value="979" />
          </valueCoding>
        </extension>
        <coding>
          <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ClaimResponse" />
          <code value="MI" />
        </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>
  <!--
  <responseCodes>
    <string>E2</string>
  </responseCodes>
  <updatedReceiptDto>
    <medCond></medCond> (reason for use code)
    <programId>TR</programId>
    <paymentStatus>U</paymentStatus>
    <planCode>T</planCode>
    <responseCds reference="../../responseCodes"/>
    <others/>
  </updatedReceiptDto>
-->
</ClaimResponse>