2nd DSTU Draft For Comment

This page is part of the FHIR Specification (v0.4.0: DSTU 2 Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

7.11 Resource PaymentReconciliation - Content

This resource maintained by the Financial Management Work Group

This resource provides payment details and claim references supporting a bulk payment.

7.11.1 Scope and Usage

The PaymentReconciliation resource provides the bulk payment details associated with a payment by the payor for goods and services rendered by a provider to patients covered by insurance plans offered by that payor. These are the payment reconciliation details which align to the individual payment amounts indicated on discrete ClaimResponses.

Bulk payments need to provide a means to associate the amounts paid again specific Claims, and other financial exchanges and adjustments, to the bulk payment itself in order to reconcile provider accounts receivable.

Todo

7.11.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. PaymentReconciliation DomainResourcePaymentReconciliation resource
... identifier 0..*IdentifierBusiness Identifier
... request 0..1PendedRequestClaim reference
... outcome 0..1codecomplete | error
RemittanceOutcome (Required)
... disposition 0..1stringDisposition Message
... ruleset 0..1CodingResource version
Ruleset (Example)
... originalRuleset 0..1CodingOriginal version
Ruleset (Example)
... created 0..1dateTimeCreation date
... period 0..1PeriodPeriod covered
... organization 0..1OrganizationInsurer
... requestProvider 0..1PractitionerResponsible practitioner
... requestOrganization 0..1OrganizationResponsible organization
... detail 0..*ElementDetails
.... type 1..1CodingType code
PaymentType (Example)
.... request 0..1AnyClaim
.... responce 0..1AnyClaim Response
.... submitter 0..1OrganizationSubmitter
.... payee 0..1OrganizationPayee
.... date 0..1dateInvoice date
.... amount 0..1MoneyDetail amount
... form 0..1CodingPrinted Form Identifier
Forms (Incomplete)
... total 1..1MoneyTotal amount of Payment
... note 0..*ElementNote text
.... type 0..1Codingdisplay | print | printoper
NoteType (Incomplete)
.... text 0..1stringNotes text

UML Diagram

PaymentReconciliation (DomainResource)The Response Business Identifieridentifier : Identifier 0..*Original request resource referencerequest : Reference(PendedRequest) 0..1Transaction status: error, completeoutcome : code 0..1 « The outcome of the processing.RemittanceOutcome »A description of the status of the adjudicationdisposition : string 0..1The version of the style of resource contents. This should be mapped to the allowable profiles for this and supporting resourcesruleset : Coding 0..1 « (The static and dynamic model to which contents conform, may be business version or standard and version.Ruleset) »The style (standard) and version of the original material which was converted into this resourceoriginalRuleset : Coding 0..1 « (The static and dynamic model to which contents conform, may be business version or standard and version.Ruleset) »The date when the enclosed suite of services were performed or completedcreated : dateTime 0..1The period of time for which payments have been gathered into this bulk payment for settlementperiod : Period 0..1The Insurer who produced this adjudicated responseorganization : Reference(Organization) 0..1The practitioner who is responsible for the services rendered to the patientrequestProvider : Reference(Practitioner) 0..1The organization which is responsible for the services rendered to the patientrequestOrganization : Reference(Organization) 0..1The form to be used for printing the contentform : Coding 0..1 « The forms codesForms+ »Total payment amounttotal : Money 1..1DetailsCode to indicate the nature of the payment, adjustment, funds advance, etctype : Coding 1..1 « (The reason for the amount: payment, adjustment, advance.PaymentType) »The claim or financial resourcerequest : Reference(Any) 0..1The claim response resourceresponce : Reference(Any) 0..1The Organization which submitted the invoice or financial transactionsubmitter : Reference(Organization) 0..1The organization which is receiving the paymentpayee : Reference(Organization) 0..1The date of the invoice or financial resourcedate : date 0..1Amount paid for this detailamount : Money 0..1NotesThe note purpose: Print/Displaytype : Coding 0..1 « The presentation types of notesNoteType+ »The note texttext : string 0..1List of individual settlement amounts and the corresponding transactiondetail0..*Suite of notesnote0..*

XML Template

<PaymentReconciliation xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier --></identifier>
 <request><!-- 0..1 Reference(PendedRequest) Claim reference --></request>
 <outcome value="[code]"/><!-- 0..1 complete | error -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <ruleset><!-- 0..1 Coding Resource version --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <period><!-- 0..1 Period Period covered --></period>
 <organization><!-- 0..1 Reference(Organization) Insurer --></organization>
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
 <detail>  <!-- 0..* Details -->
  <type><!-- 1..1 Coding Type code --></type>
  <request><!-- 0..1 Reference(Any) Claim --></request>
  <responce><!-- 0..1 Reference(Any) Claim Response --></responce>
  <submitter><!-- 0..1 Reference(Organization) Submitter --></submitter>
  <payee><!-- 0..1 Reference(Organization) Payee --></payee>
  <date value="[date]"/><!-- 0..1 Invoice date -->
  <amount><!-- 0..1 Money Detail amount --></amount>
 </detail>
 <form><!-- 0..1 Coding Printed Form Identifier --></form>
 <total><!-- 1..1 Money Total amount of Payment --></total>
 <note>  <!-- 0..* Note text -->
  <type><!-- 0..1 Coding display | print | printoper --></type>
  <text value="[string]"/><!-- 0..1 Notes text -->
 </note>
</PaymentReconciliation>

JSON Template

{doco
  "resourceType" : "PaymentReconciliation",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier
  "request" : { Reference(PendedRequest) }, // Claim reference
  "outcome" : "<code>", // complete | error
  "disposition" : "<string>", // Disposition Message
  "ruleset" : { Coding }, // Resource version
  "originalRuleset" : { Coding }, // Original version
  "created" : "<dateTime>", // Creation date
  "period" : { Period }, // Period covered
  "organization" : { Reference(Organization) }, // Insurer
  "requestProvider" : { Reference(Practitioner) }, // Responsible practitioner
  "requestOrganization" : { Reference(Organization) }, // Responsible organization
  "detail" : [{ // Details
    "type" : { Coding }, // R! Type code
    "request" : { Reference(Any) }, // Claim
    "responce" : { Reference(Any) }, // Claim Response
    "submitter" : { Reference(Organization) }, // Submitter
    "payee" : { Reference(Organization) }, // Payee
    "date" : "<date>", // Invoice date
    "amount" : { Money } // Detail amount
  }],
  "form" : { Coding }, // Printed Form Identifier
  "total" : { Money }, // R! Total amount of Payment
  "note" : [{ // Note text
    "type" : { Coding }, // display | print | printoper
    "text" : "<string>" // Notes text
  }]
}

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. PaymentReconciliation DomainResourcePaymentReconciliation resource
... identifier 0..*IdentifierBusiness Identifier
... request 0..1PendedRequestClaim reference
... outcome 0..1codecomplete | error
RemittanceOutcome (Required)
... disposition 0..1stringDisposition Message
... ruleset 0..1CodingResource version
Ruleset (Example)
... originalRuleset 0..1CodingOriginal version
Ruleset (Example)
... created 0..1dateTimeCreation date
... period 0..1PeriodPeriod covered
... organization 0..1OrganizationInsurer
... requestProvider 0..1PractitionerResponsible practitioner
... requestOrganization 0..1OrganizationResponsible organization
... detail 0..*ElementDetails
.... type 1..1CodingType code
PaymentType (Example)
.... request 0..1AnyClaim
.... responce 0..1AnyClaim Response
.... submitter 0..1OrganizationSubmitter
.... payee 0..1OrganizationPayee
.... date 0..1dateInvoice date
.... amount 0..1MoneyDetail amount
... form 0..1CodingPrinted Form Identifier
Forms (Incomplete)
... total 1..1MoneyTotal amount of Payment
... note 0..*ElementNote text
.... type 0..1Codingdisplay | print | printoper
NoteType (Incomplete)
.... text 0..1stringNotes text

UML Diagram

PaymentReconciliation (DomainResource)The Response Business Identifieridentifier : Identifier 0..*Original request resource referencerequest : Reference(PendedRequest) 0..1Transaction status: error, completeoutcome : code 0..1 « The outcome of the processing.RemittanceOutcome »A description of the status of the adjudicationdisposition : string 0..1The version of the style of resource contents. This should be mapped to the allowable profiles for this and supporting resourcesruleset : Coding 0..1 « (The static and dynamic model to which contents conform, may be business version or standard and version.Ruleset) »The style (standard) and version of the original material which was converted into this resourceoriginalRuleset : Coding 0..1 « (The static and dynamic model to which contents conform, may be business version or standard and version.Ruleset) »The date when the enclosed suite of services were performed or completedcreated : dateTime 0..1The period of time for which payments have been gathered into this bulk payment for settlementperiod : Period 0..1The Insurer who produced this adjudicated responseorganization : Reference(Organization) 0..1The practitioner who is responsible for the services rendered to the patientrequestProvider : Reference(Practitioner) 0..1The organization which is responsible for the services rendered to the patientrequestOrganization : Reference(Organization) 0..1The form to be used for printing the contentform : Coding 0..1 « The forms codesForms+ »Total payment amounttotal : Money 1..1DetailsCode to indicate the nature of the payment, adjustment, funds advance, etctype : Coding 1..1 « (The reason for the amount: payment, adjustment, advance.PaymentType) »The claim or financial resourcerequest : Reference(Any) 0..1The claim response resourceresponce : Reference(Any) 0..1The Organization which submitted the invoice or financial transactionsubmitter : Reference(Organization) 0..1The organization which is receiving the paymentpayee : Reference(Organization) 0..1The date of the invoice or financial resourcedate : date 0..1Amount paid for this detailamount : Money 0..1NotesThe note purpose: Print/Displaytype : Coding 0..1 « The presentation types of notesNoteType+ »The note texttext : string 0..1List of individual settlement amounts and the corresponding transactiondetail0..*Suite of notesnote0..*

XML Template

<PaymentReconciliation xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier --></identifier>
 <request><!-- 0..1 Reference(PendedRequest) Claim reference --></request>
 <outcome value="[code]"/><!-- 0..1 complete | error -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <ruleset><!-- 0..1 Coding Resource version --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <period><!-- 0..1 Period Period covered --></period>
 <organization><!-- 0..1 Reference(Organization) Insurer --></organization>
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
 <detail>  <!-- 0..* Details -->
  <type><!-- 1..1 Coding Type code --></type>
  <request><!-- 0..1 Reference(Any) Claim --></request>
  <responce><!-- 0..1 Reference(Any) Claim Response --></responce>
  <submitter><!-- 0..1 Reference(Organization) Submitter --></submitter>
  <payee><!-- 0..1 Reference(Organization) Payee --></payee>
  <date value="[date]"/><!-- 0..1 Invoice date -->
  <amount><!-- 0..1 Money Detail amount --></amount>
 </detail>
 <form><!-- 0..1 Coding Printed Form Identifier --></form>
 <total><!-- 1..1 Money Total amount of Payment --></total>
 <note>  <!-- 0..* Note text -->
  <type><!-- 0..1 Coding display | print | printoper --></type>
  <text value="[string]"/><!-- 0..1 Notes text -->
 </note>
</PaymentReconciliation>

JSON Template

{doco
  "resourceType" : "PaymentReconciliation",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier
  "request" : { Reference(PendedRequest) }, // Claim reference
  "outcome" : "<code>", // complete | error
  "disposition" : "<string>", // Disposition Message
  "ruleset" : { Coding }, // Resource version
  "originalRuleset" : { Coding }, // Original version
  "created" : "<dateTime>", // Creation date
  "period" : { Period }, // Period covered
  "organization" : { Reference(Organization) }, // Insurer
  "requestProvider" : { Reference(Practitioner) }, // Responsible practitioner
  "requestOrganization" : { Reference(Organization) }, // Responsible organization
  "detail" : [{ // Details
    "type" : { Coding }, // R! Type code
    "request" : { Reference(Any) }, // Claim
    "responce" : { Reference(Any) }, // Claim Response
    "submitter" : { Reference(Organization) }, // Submitter
    "payee" : { Reference(Organization) }, // Payee
    "date" : "<date>", // Invoice date
    "amount" : { Money } // Detail amount
  }],
  "form" : { Coding }, // Printed Form Identifier
  "total" : { Money }, // R! Total amount of Payment
  "note" : [{ // Note text
    "type" : { Coding }, // display | print | printoper
    "text" : "<string>" // Notes text
  }]
}

 

Alternate definitions: Schema/Schematron, Resource Profile (XML, JSON), Questionnaire

7.11.2.1 Terminology Bindings

PathDefinitionTypeReference
PaymentReconciliation.outcome The outcome of the processing.Fixedhttp://hl7.org/fhir/RS-link
PaymentReconciliation.ruleset
PaymentReconciliation.originalRuleset 		The static and dynamic model to which contents conform, may be business version or standard and version.Examplehttp://hl7.org/fhir/vs/ruleset
PaymentReconciliation.detail.type The reason for the amount: payment, adjustment, advance.Examplehttp://hl7.org/fhir/vs/payment-type
PaymentReconciliation.form The forms codesIncompletehttp://hl7.org/fhir/vs/forms
PaymentReconciliation.note.type The presentation types of notesFixedhttp://hl7.org/fhir/NT-link

7.11.3 Search Parameters

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

NameTypeDescriptionPaths
identifiertokenThe business identifier of the Explanation of BenefitPaymentReconciliation.identifier