<ExplanationOfBenefit 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">
  <!-- id will typically be omitted.  It is included here due to publishing requiremeents -->
  <id value="example-ExplanationOfBenefit-receipts" />
  <contained>
    <MedicationDispense>
      <id value="dispense1" />
      <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-MedicationDispense-PrescriberLicense">
        <valueCoding>
          <system value="https://bpcs.exchange/fhir/CodeSystem/cs-PrescriberLicense" />
          <code value="99" />
          <display value="Unknown" />
        </valueCoding>
      </extension>
      <identifier>
        <value value="2" />
      </identifier>
      <status value="completed" />
      <medication>
        <concept>
          <coding>
            <system value="http://hl7.org/fhir/NamingSystem/ca-hc-din" />
            <code value="2225166" />
          </coding>
        </concept>
      </medication>
      <subject>
        <!-- This would normally be the odbNum -->
        <reference value="Patient/example-Patient" />
      </subject>
      <quantity>
        <value value="6.0" />
      </quantity>
      <whenHandedOver value="2022-08-05" />
    </MedicationDispense>
  </contained>
  <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 RA101794622" />
  </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="#dispense1" />
    </valueReference>
  </supportingInfo>
  <item>
    <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-ReceiptPatient">
      <valueReference>
        <!-- This would normally be the odbNum -->
        <reference value="Patient/example-Patient" />
      </valueReference>
    </extension>
    <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ExplanationOfBenefit-ItemSource">
      <valueIdentifier>
        <system value="https://bpcs.exchange/fhir/NamingSystem/receipt-source" />
        <value value="bpcs" />
      </valueIdentifier>
    </extension>
    <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-ExplanationOfBenefit-Claim">
      <valueString value="http://example.org/fhir/Claim/RA101794622-20220805-2" />
    </extension>
    <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Claim-DuplicateVersion">
      <valueUnsignedInt value="1" />
    </extension>
    <extension url="https://bpcs.exchange/fhir/StructureDefinition/ext-Resource-Mode">
      <valueCoding>
        <system value="http://terminology.hl7.org/CodeSystem/v3-ParticipationMode" />
        <code value="MAILWRIT" />
        <display value="mail" />
      </valueCoding>
    </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-ExplanationOfBenefit-AdjudicationDate">
      <valueDate value="2023-10-16" />
    </extension>
    <sequence value="1" />
    <informationSequence value="1" />
    <productOrService>
      <coding>
        <system value="http://hl7.org/fhir/NamingSystem/ca-hc-din" />
        <code value="2225166" />
        <display value="Suprefact" />
      </coding>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/hc-CCDD" />
        <display value="BUSERELIN ACETATE" />
      </coding>
    </productOrService>
    <!--    <modifier>   ReceiptDTO.nfbFormInd       <coding>        <system value=""/>        <code value="E1"/>      </coding>    </modifier>    <modifier>   ReceiptDTO.responseCds      <coding>        <system value=""/>        <code value=""/>      </coding>    </modifier>-->
    <servicedDate value="2022-08-05" />
    <patientPaid>
      <value value="6.0" />
      <currency value="CAD" />
    </patientPaid>
    <quantity>
      <value value="6.0" />
    </quantity>
    <reviewOutcome>
      <decision>
        <coding>
          <system value="https://bpcs.exchange/fhir/CodeSystem/cs-ReceiptStatus" />
          <code value="acceptedReversed" />
        </coding>
      </decision>
    </reviewOutcome>
    <adjudication>
      <category>
        <coding>
          <system value="http://terminology.hl7.org/CodeSystem/adjudication" />
          <code value="submitted" />
        </coding>
      </category>
      <amount>
        <value value="6" />
        <currency value="CAD" />
      </amount>
    </adjudication>
    <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>
    <detail>
      <sequence value="1" />
      <productOrService>
        <coding>
          <system value="https://bpcs.exchange/fhir/CodeSystem/cs-CostFee" />
          <code value="drugCost" />
        </coding>
      </productOrService>
      <net>
        <value value="6.0" />
        <currency value="CAD" />
      </net>
    </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="6.0" />
          <currency value="CAD" />
        </amount>
      </adjudication>
    </detail>
  </item>
</ExplanationOfBenefit>