STU 3 Candidate

This page is part of the FHIR Specification (v1.4.0: STU 3 Ballot 3). 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

7.10 Resource PaymentReconciliation - Content

Financial Management Work GroupMaturity Level: 0Compartments: Not linked to any defined compartments

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

7.10.1 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

7.10.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. PaymentReconciliation ΣDomainResourcePaymentReconciliation resource
... identifier Σ0..*IdentifierBusiness Identifier
... request[x] Σ0..1Claim reference
.... requestIdentifierIdentifier
.... requestReferenceReference(ProcessRequest)
... outcome Σ0..1codecomplete | error
RemittanceOutcome (Required)
... disposition Σ0..1stringDisposition Message
... ruleset Σ0..1CodingResource version
Ruleset Codes (Example)
... originalRuleset Σ0..1CodingOriginal version
Ruleset Codes (Example)
... created Σ0..1dateTimeCreation date
... period Σ0..1PeriodPeriod covered
... organization[x] Σ0..1Insurer
.... organizationIdentifierIdentifier
.... organizationReferenceReference(Organization)
... requestProvider[x] Σ0..1Responsible practitioner
.... requestProviderIdentifierIdentifier
.... requestProviderReferenceReference(Practitioner)
... requestOrganization[x] Σ0..1Responsible organization
.... requestOrganizationIdentifierIdentifier
.... requestOrganizationReferenceReference(Organization)
... detail Σ0..*BackboneElementDetails
.... type Σ1..1CodingType code
Payment Type Codes (Example)
.... request[x] Σ0..1Claim
..... requestIdentifierIdentifier
..... requestReferenceReference(Any)
.... responce[x] Σ0..1Claim Response
..... responceIdentifierIdentifier
..... responceReferenceReference(Any)
.... submitter[x] Σ0..1Submitter
..... submitterIdentifierIdentifier
..... submitterReferenceReference(Organization)
.... payee[x] Σ0..1Payee
..... payeeIdentifierIdentifier
..... payeeReferenceReference(Organization)
.... date Σ0..1dateInvoice date
.... amount Σ0..1MoneyDetail amount
... form Σ0..1CodingPrinted Form Identifier
Form Codes (Required)
... total Σ1..1MoneyTotal amount of Payment
... note Σ0..*BackboneElementNote text
.... type Σ0..1Codingdisplay | print | printoper
NoteType (Required)
.... text Σ0..1stringNotes text

doco Documentation for this format

UML Diagram

PaymentReconciliation (DomainResource)The Response business identifieridentifier : Identifier [0..*]Original request resource referencerequest[x] : Type [0..1] « Identifier|Reference(ProcessRequest) »Transaction status: error, completeoutcome : code [0..1] « The outcome of the processing. (Strength=Required)RemittanceOutcome! »A description of the status of the adjudicationdisposition : string [0..1]The 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, which may be business version or standard/version. (Strength=Example)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, which may be business version or standard/version. (Strength=Example)Ruleset ?? »The date when the enclosed suite of services were performed or completedcreated : dateTime [0..1]The period of time for which payments have been gathered into this bulk payment for settlementperiod : Period [0..1]The Insurer who produced this adjudicated responseorganization[x] : Type [0..1] « Identifier|Reference(Organization) »The practitioner who is responsible for the services rendered to the patientrequestProvider[x] : Type [0..1] « Identifier|Reference(Practitioner) »The organization which is responsible for the services rendered to the patientrequestOrganization[x] : Type [0..1] « Identifier|Reference( Organization) »The form to be used for printing the contentform : Coding [0..1] « The forms codes. (Strength=Required)Form ! »Total payment amounttotal : Quantity(Money) [1..1]DetailsCode to indicate the nature of the payment, adjustment, funds advance, etctype : Coding [1..1] « The reason for the amount: payment, adjustment, advance. (Strength=Example)Payment Type ?? »The claim or financial resourcerequest[x] : Type [0..1] « Identifier|Reference(Any) »The claim response resourceresponce[x] : Type [0..1] « Identifier|Reference(Any) »The Organization which submitted the invoice or financial transactionsubmitter[x] : Type [0..1] « Identifier|Reference(Organization) »The organization which is receiving the paymentpayee[x] : Type [0..1] « Identifier|Reference(Organization) »The date of the invoice or financial resourcedate : date [0..1]Amount paid for this detailamount : Quantity(Money) [0..1]NotesThe note purpose: Print/Displaytype : Coding [0..1] « The presentation types of notes. (Strength=Required)NoteType! »The note texttext : string [0..1]List of individual settlement amounts and the corresponding transactiondetail[0..*]Suite of notesnote[0..*]

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[x]><!-- 0..1 Identifier|Reference(ProcessRequest) Claim reference --></request[x]>
 <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[x]><!-- 0..1 Identifier|Reference(Organization) Insurer --></organization[x]>
 <requestProvider[x]><!-- 0..1 Identifier|Reference(Practitioner) Responsible practitioner --></requestProvider[x]>
 <requestOrganization[x]><!-- 0..1 Identifier|Reference(Organization) Responsible organization --></requestOrganization[x]>
 <detail>  <!-- 0..* Details -->
  <type><!-- 1..1 Coding Type code --></type>
  <request[x]><!-- 0..1 Identifier|Reference(Any) Claim --></request[x]>
  <responce[x]><!-- 0..1 Identifier|Reference(Any) Claim Response --></responce[x]>
  <submitter[x]><!-- 0..1 Identifier|Reference(Organization) Submitter --></submitter[x]>
  <payee[x]><!-- 0..1 Identifier|Reference(Organization) Payee --></payee[x]>
  <date value="[date]"/><!-- 0..1 Invoice date -->
  <amount><!-- 0..1 Quantity(Money) Detail amount --></amount>
 </detail>
 <form><!-- 0..1 Coding Printed Form Identifier --></form>
 <total><!-- 1..1 Quantity(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[x]: Claim reference. One of these 2:
  "requestIdentifier" : { Identifier },
  "requestReference" : { Reference(ProcessRequest) },
  "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[x]: Insurer. One of these 2:
  "organizationIdentifier" : { Identifier },
  "organizationReference" : { Reference(Organization) },
  // requestProvider[x]: Responsible practitioner. One of these 2:
  "requestProviderIdentifier" : { Identifier },
  "requestProviderReference" : { Reference(Practitioner) },
  // requestOrganization[x]: Responsible organization. One of these 2:
  "requestOrganizationIdentifier" : { Identifier },
  "requestOrganizationReference" : { Reference(Organization) },
  "detail" : [{ // Details
    "type" : { Coding }, // R!  Type code
    // request[x]: Claim. One of these 2:
    "requestIdentifier" : { Identifier },
    "requestReference" : { Reference(Any) },
    // responce[x]: Claim Response. One of these 2:
    "responceIdentifier" : { Identifier },
    "responceReference" : { Reference(Any) },
    // submitter[x]: Submitter. One of these 2:
    "submitterIdentifier" : { Identifier },
    "submitterReference" : { Reference(Organization) },
    // payee[x]: Payee. One of these 2:
    "payeeIdentifier" : { Identifier },
    "payeeReference" : { Reference(Organization) },
    "date" : "<date>", // Invoice date
    "amount" : { Quantity(Money) } // Detail amount
  }],
  "form" : { Coding }, // Printed Form Identifier
  "total" : { Quantity(Money) }, // R!  Total amount of Payment
  "note" : [{ // Note text
    "type" : { Coding }, // display | print | printoper
    "text" : "<string>" // Notes text
  }]
}

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. PaymentReconciliation ΣDomainResourcePaymentReconciliation resource
... identifier Σ0..*IdentifierBusiness Identifier
... request[x] Σ0..1Claim reference
.... requestIdentifierIdentifier
.... requestReferenceReference(ProcessRequest)
... outcome Σ0..1codecomplete | error
RemittanceOutcome (Required)
... disposition Σ0..1stringDisposition Message
... ruleset Σ0..1CodingResource version
Ruleset Codes (Example)
... originalRuleset Σ0..1CodingOriginal version
Ruleset Codes (Example)
... created Σ0..1dateTimeCreation date
... period Σ0..1PeriodPeriod covered
... organization[x] Σ0..1Insurer
.... organizationIdentifierIdentifier
.... organizationReferenceReference(Organization)
... requestProvider[x] Σ0..1Responsible practitioner
.... requestProviderIdentifierIdentifier
.... requestProviderReferenceReference(Practitioner)
... requestOrganization[x] Σ0..1Responsible organization
.... requestOrganizationIdentifierIdentifier
.... requestOrganizationReferenceReference(Organization)
... detail Σ0..*BackboneElementDetails
.... type Σ1..1CodingType code
Payment Type Codes (Example)
.... request[x] Σ0..1Claim
..... requestIdentifierIdentifier
..... requestReferenceReference(Any)
.... responce[x] Σ0..1Claim Response
..... responceIdentifierIdentifier
..... responceReferenceReference(Any)
.... submitter[x] Σ0..1Submitter
..... submitterIdentifierIdentifier
..... submitterReferenceReference(Organization)
.... payee[x] Σ0..1Payee
..... payeeIdentifierIdentifier
..... payeeReferenceReference(Organization)
.... date Σ0..1dateInvoice date
.... amount Σ0..1MoneyDetail amount
... form Σ0..1CodingPrinted Form Identifier
Form Codes (Required)
... total Σ1..1MoneyTotal amount of Payment
... note Σ0..*BackboneElementNote text
.... type Σ0..1Codingdisplay | print | printoper
NoteType (Required)
.... text Σ0..1stringNotes text

doco Documentation for this format

UML Diagram

PaymentReconciliation (DomainResource)The Response business identifieridentifier : Identifier [0..*]Original request resource referencerequest[x] : Type [0..1] « Identifier|Reference(ProcessRequest) »Transaction status: error, completeoutcome : code [0..1] « The outcome of the processing. (Strength=Required)RemittanceOutcome! »A description of the status of the adjudicationdisposition : string [0..1]The 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, which may be business version or standard/version. (Strength=Example)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, which may be business version or standard/version. (Strength=Example)Ruleset ?? »The date when the enclosed suite of services were performed or completedcreated : dateTime [0..1]The period of time for which payments have been gathered into this bulk payment for settlementperiod : Period [0..1]The Insurer who produced this adjudicated responseorganization[x] : Type [0..1] « Identifier|Reference(Organization) »The practitioner who is responsible for the services rendered to the patientrequestProvider[x] : Type [0..1] « Identifier|Reference(Practitioner) »The organization which is responsible for the services rendered to the patientrequestOrganization[x] : Type [0..1] « Identifier|Reference( Organization) »The form to be used for printing the contentform : Coding [0..1] « The forms codes. (Strength=Required)Form ! »Total payment amounttotal : Quantity(Money) [1..1]DetailsCode to indicate the nature of the payment, adjustment, funds advance, etctype : Coding [1..1] « The reason for the amount: payment, adjustment, advance. (Strength=Example)Payment Type ?? »The claim or financial resourcerequest[x] : Type [0..1] « Identifier|Reference(Any) »The claim response resourceresponce[x] : Type [0..1] « Identifier|Reference(Any) »The Organization which submitted the invoice or financial transactionsubmitter[x] : Type [0..1] « Identifier|Reference(Organization) »The organization which is receiving the paymentpayee[x] : Type [0..1] « Identifier|Reference(Organization) »The date of the invoice or financial resourcedate : date [0..1]Amount paid for this detailamount : Quantity(Money) [0..1]NotesThe note purpose: Print/Displaytype : Coding [0..1] « The presentation types of notes. (Strength=Required)NoteType! »The note texttext : string [0..1]List of individual settlement amounts and the corresponding transactiondetail[0..*]Suite of notesnote[0..*]

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[x]><!-- 0..1 Identifier|Reference(ProcessRequest) Claim reference --></request[x]>
 <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[x]><!-- 0..1 Identifier|Reference(Organization) Insurer --></organization[x]>
 <requestProvider[x]><!-- 0..1 Identifier|Reference(Practitioner) Responsible practitioner --></requestProvider[x]>
 <requestOrganization[x]><!-- 0..1 Identifier|Reference(Organization) Responsible organization --></requestOrganization[x]>
 <detail>  <!-- 0..* Details -->
  <type><!-- 1..1 Coding Type code --></type>
  <request[x]><!-- 0..1 Identifier|Reference(Any) Claim --></request[x]>
  <responce[x]><!-- 0..1 Identifier|Reference(Any) Claim Response --></responce[x]>
  <submitter[x]><!-- 0..1 Identifier|Reference(Organization) Submitter --></submitter[x]>
  <payee[x]><!-- 0..1 Identifier|Reference(Organization) Payee --></payee[x]>
  <date value="[date]"/><!-- 0..1 Invoice date -->
  <amount><!-- 0..1 Quantity(Money) Detail amount --></amount>
 </detail>
 <form><!-- 0..1 Coding Printed Form Identifier --></form>
 <total><!-- 1..1 Quantity(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[x]: Claim reference. One of these 2:
  "requestIdentifier" : { Identifier },
  "requestReference" : { Reference(ProcessRequest) },
  "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[x]: Insurer. One of these 2:
  "organizationIdentifier" : { Identifier },
  "organizationReference" : { Reference(Organization) },
  // requestProvider[x]: Responsible practitioner. One of these 2:
  "requestProviderIdentifier" : { Identifier },
  "requestProviderReference" : { Reference(Practitioner) },
  // requestOrganization[x]: Responsible organization. One of these 2:
  "requestOrganizationIdentifier" : { Identifier },
  "requestOrganizationReference" : { Reference(Organization) },
  "detail" : [{ // Details
    "type" : { Coding }, // R!  Type code
    // request[x]: Claim. One of these 2:
    "requestIdentifier" : { Identifier },
    "requestReference" : { Reference(Any) },
    // responce[x]: Claim Response. One of these 2:
    "responceIdentifier" : { Identifier },
    "responceReference" : { Reference(Any) },
    // submitter[x]: Submitter. One of these 2:
    "submitterIdentifier" : { Identifier },
    "submitterReference" : { Reference(Organization) },
    // payee[x]: Payee. One of these 2:
    "payeeIdentifier" : { Identifier },
    "payeeReference" : { Reference(Organization) },
    "date" : "<date>", // Invoice date
    "amount" : { Quantity(Money) } // Detail amount
  }],
  "form" : { Coding }, // Printed Form Identifier
  "total" : { Quantity(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

7.10.2.1 Terminology Bindings

PathDefinitionTypeReference
PaymentReconciliation.outcome The outcome of the processing.RequiredRemittanceOutcome
PaymentReconciliation.ruleset
PaymentReconciliation.originalRuleset 		The static and dynamic model to which contents conform, which may be business version or standard/version.ExampleRuleset Codes
PaymentReconciliation.detail.type The reason for the amount: payment, adjustment, advance.ExamplePayment Type Codes
PaymentReconciliation.form The forms codes.RequiredForm Codes
PaymentReconciliation.note.type The presentation types of notes.RequiredNoteType

7.10.3 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
createddateThe creation datePaymentReconciliation.created
dispositionstringThe contents of the disposition messagePaymentReconciliation.disposition
identifiertokenThe business identifier of the Explanation of BenefitPaymentReconciliation.identifier
organizationidentifiertokenThe organization who generated this resourcePaymentReconciliation.organizationIdentifier
organizationreferencereferenceThe organization who generated this resourcePaymentReconciliation.organizationReference
(Organization)
outcometokenThe processing outcomePaymentReconciliation.outcome
requestidentifiertokenThe reference to the claimPaymentReconciliation.requestIdentifier
requestorganizationidentifiertokenThe organization who generated this resourcePaymentReconciliation.requestOrganizationIdentifier
requestorganizationreferencereferenceThe organization who generated this resourcePaymentReconciliation.requestOrganizationReference
(Organization)
requestprovideridentifiertokenThe reference to the provider who sumbitted the claimPaymentReconciliation.requestProviderIdentifier
requestproviderreferencereferenceThe reference to the provider who sumbitted the claimPaymentReconciliation.requestProviderReference
(Practitioner)
requestreferencereferenceThe reference to the claimPaymentReconciliation.requestReference
(ProcessRequest)