Paymentreconciliation-example.xml

General Payment Reconciliation Example (id = "ER2500")

<PaymentReconciliation xmlns="http://hl7.org/fhir">
 <id value="ER2500"/>

 <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the PaymentReconciliation</div>
  </text>

  <identifier>
    <system value="http://www.BenefitsInc.com/fhir/enrollmentresponse"/>
    <value value="781234"/>
  </identifier>
  
  <status value="active"/>

  <created value="2014-08-16"/>

  <organization>
    <reference value="Organization/2"/>
  </organization>

  <request>
  <reference value="http://www.BenefitsInc.com/fhir/eligibility/225476332402"/>
  </request>
  
  <outcome>
   <coding>
    <system value="http://hl7.org/fhir/remittance-outcome"/>
  <code value="complete"/>
   </coding>
  </outcome>
  
  <disposition value="2014 August mid-month settlement."/>
 
  <requestOrganization>
    <reference value="Organization/1"/>
  </requestOrganization>
 
  <detail>
  <type>
    <coding>
     <system value="http://hl7.org/fhir/paymenttype"/>
     <code value="payment"/>
   </coding>
  </type>
  <request>
    <reference value="http://www.BenefitsInc.com/fhir/oralhealthclaim/225476332402"/>
  </request>
  <date value="2014-08-16"/>
  <amount>
    <value value="1000.00"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </amount>   
  </detail>
 
  <detail>
  <type>
    <coding>
     <system value="http://hl7.org/fhir/paymenttype"/>
     <code value="payment"/>
   </coding>
  </type>
  <request>
    <reference value="http://www.BenefitsInc.com/fhir/oralhealthclaim/225476332699"/>
  </request>
  <date value="2014-08-12"/>
  <amount>
    <value value="4000.00"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </amount>   
  </detail>
 
  <detail>
  <type>
    <coding>
     <system value="http://hl7.org/fhir/paymenttype"/>
     <code value="advance"/>
   </coding>
  </type>
  <date value="2014-08-16"/>
  <amount>
    <value value="-1500.00"/>
    <system value="urn:iso:std:iso:4217"/>
    <code value="USD"/>
  </amount>   
  </detail>
  
  <total>
  <value value="3500.00"/>
  <system value="urn:iso:std:iso:4217"/>
  <code value="USD"/>
  </total>  
 
</PaymentReconciliation>