{
  "resourceType": "ExplanationOfBenefit",
  "id": "example-ExplanationOfBenefit-receipts",
  "contained": [
    {
      "resourceType": "MedicationDispense",
      "id": "dispense1",
      "extension": [
        {
          "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-MedicationDispense-PrescriberLicense",
          "valueCoding": {
            "system": "https://bpcs.exchange/fhir/CodeSystem/cs-PrescriberLicense",
            "code": "99",
            "display": "Unknown"
          }
        }
      ],
      "identifier": [
        {
          "value": "2"
        }
      ],
      "status": "completed",
      "medication": {
        "concept": {
          "coding": [
            {
              "system": "http://hl7.org/fhir/NamingSystem/ca-hc-din",
              "code": "2225166"
            }
          ]
        }
      },
      "subject": {
        "reference": "Patient/example-Patient"
      },
      "quantity": {
        "value": 6.0
      },
      "whenHandedOver": "2022-08-05"
    }
  ],
  "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/example-Group"
        }
      }
    ],
    "display": "Family RA101794622"
  },
  "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": "#dispense1"
      }
    }
  ],
  "item": [
    {
      "extension": [
        {
          "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-ReceiptPatient",
          "valueReference": {
            "reference": "Patient/example-Patient"
          }
        },
        {
          "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-ExplanationOfBenefit-ItemSource",
          "valueIdentifier": {
            "system": "https://bpcs.exchange/fhir/NamingSystem/receipt-source",
            "value": "bpcs"
          }
        },
        {
          "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-ExplanationOfBenefit-Claim",
          "valueString": "http://example.org/fhir/Claim/RA101794622-20220805-2"
        },
        {
          "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-DuplicateVersion",
          "valueUnsignedInt": 1
        },
        {
          "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-Resource-Mode",
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationMode",
            "code": "MAILWRIT",
            "display": "mail"
          }
        },
        {
          "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-Resource-ReceiptPlan",
          "valueCoding": {
            "system": "https://bpcs.exchange/fhir/CodeSystem/cs-ProgramPlan",
            "code": "T"
          }
        },
        {
          "url": "https://bpcs.exchange/fhir/StructureDefinition/ext-ExplanationOfBenefit-AdjudicationDate",
          "valueDate": "2023-10-16"
        }
      ],
      "sequence": 1,
      "informationSequence": [
        1
      ],
      "productOrService": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/NamingSystem/ca-hc-din",
            "code": "2225166",
            "display": "Suprefact"
          },
          {
            "system": "http://terminology.hl7.org/CodeSystem/hc-CCDD",
            "display": "BUSERELIN ACETATE"
          }
        ]
      },
      "servicedDate": "2022-08-05",
      "patientPaid": {
        "value": 6.0,
        "currency": "CAD"
      },
      "quantity": {
        "value": 6.0
      },
      "reviewOutcome": {
        "decision": {
          "coding": [
            {
              "system": "https://bpcs.exchange/fhir/CodeSystem/cs-ReceiptStatus",
              "code": "acceptedReversed"
            }
          ]
        }
      },
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/adjudication",
                "code": "submitted"
              }
            ]
          },
          "amount": {
            "value": 6,
            "currency": "CAD"
          }
        },
        {
          "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"
          }
        }
      ],
      "detail": [
        {
          "sequence": 1,
          "productOrService": {
            "coding": [
              {
                "system": "https://bpcs.exchange/fhir/CodeSystem/cs-CostFee",
                "code": "drugCost"
              }
            ]
          },
          "net": {
            "value": 6.0,
            "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": 6.0,
                "currency": "CAD"
              }
            }
          ]
        }
      ]
    }
  ]
}