STU3 Candidate

This page is part of the FHIR Specification (v1.8.0: STU 3 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

13.10 Resource PaymentReconciliation - Content

Financial Management Work GroupMaturity Level: 1Compartments: Not linked to any defined compartments

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

13.10.1 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.

13.10.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. PaymentReconciliation DomainResourcePaymentReconciliation resource
... identifier 0..*IdentifierBusiness Identifier
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... period 0..1PeriodPeriod covered
... created 0..1dateTimeCreation date
... organization 0..1Reference(Organization)Insurer
... request 0..1Reference(ProcessRequest)Claim reference
... outcome 0..1CodeableConceptcomplete | error | partial
RemittanceOutcome (Required)
... disposition 0..1stringDisposition Message
... requestProvider 0..1Reference(Practitioner)Responsible practitioner
... requestOrganization 0..1Reference(Organization)Responsible organization
... detail 0..*BackboneElementDetails
.... type 1..1CodeableConceptType code
Payment Type Codes (Example)
.... request 0..1Reference(Any)Claim
.... response 0..1Reference(Any)Claim Response
.... submitter 0..1Reference(Organization)Submitter
.... payee 0..1Reference(Organization)Payee
.... date 0..1dateInvoice date
.... amount 0..1MoneyDetail amount
... form 0..1CodeableConceptPrinted Form Identifier
Form Codes (Required)
... total 0..1MoneyTotal amount of Payment
... note 0..*BackboneElementNote text
.... type 0..1CodeableConceptdisplay | print | printoper
NoteType (Required)
.... text 0..1stringNotes text

doco Documentation for this format

UML Diagram (Legend)

PaymentReconciliation (DomainResource)The Response business identifieridentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [0..1] « A code specifying the state of the resource instance. (Strength=Required)Financial Resource Status ! »The period of time for which payments have been gathered into this bulk payment for settlementperiod : Period [0..1]The date when the enclosed suite of services were performed or completedcreated : dateTime [0..1]The Insurer who produced this adjudicated responseorganization : Reference [0..1] « Organization »Original request resource referencerequest : Reference [0..1] « ProcessRequest »Transaction status: error, completeoutcome : CodeableConcept [0..1] « The outcome of the processing. (Strength=Required)RemittanceOutcome! »A description of the status of the adjudicationdisposition : string [0..1]The practitioner who is responsible for the services rendered to the patientrequestProvider : Reference [0..1] « Practitioner »The organization which is responsible for the services rendered to the patientrequestOrganization : Reference [0..1] « Organization »The form to be used for printing the contentform : CodeableConcept [0..1] « The forms codes. (Strength=Required)Form ! »Total payment amounttotal : Money [0..1]DetailsCode to indicate the nature of the payment, adjustment, funds advance, etctype : CodeableConcept [1..1] « The reason for the amount: payment, adjustment, advance. (Strength=Example)Payment Type ?? »The claim or financial resourcerequest : Reference [0..1] « Any »The claim response resourceresponse : Reference [0..1] « Any »The Organization which submitted the invoice or financial transactionsubmitter : Reference [0..1] « Organization »The organization which is receiving the paymentpayee : Reference [0..1] « Organization »The date of the invoice or financial resourcedate : date [0..1]Amount paid for this detailamount : Money [0..1]NotesThe note purpose: Print/Displaytype : CodeableConcept [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>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <period><!-- 0..1 Period Period covered --></period>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <organization><!-- 0..1 Reference(Organization) Insurer --></organization>
 <request><!-- 0..1 Reference(ProcessRequest) Claim reference --></request>
 <outcome><!-- 0..1 CodeableConcept complete | error | partial --></outcome>
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
 <detail>  <!-- 0..* Details -->
  <type><!-- 1..1 CodeableConcept Type code --></type>
  <request><!-- 0..1 Reference(Any) Claim --></request>
  <response><!-- 0..1 Reference(Any) Claim Response --></response>
  <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 CodeableConcept Printed Form Identifier --></form>
 <total><!-- 0..1 Money Total amount of Payment --></total>
 <note>  <!-- 0..* Note text -->
  <type><!-- 0..1 CodeableConcept display | print | printoper --></type>
  <text value="[string]"/><!-- 0..1 Notes text -->
 </note>
</PaymentReconciliation>

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:PaymentReconciliation;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:PaymentReconciliation.identifier [ Identifier ], ... ; # 0..* Business Identifier
  fhir:PaymentReconciliation.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:PaymentReconciliation.period [ Period ]; # 0..1 Period covered
  fhir:PaymentReconciliation.created [ dateTime ]; # 0..1 Creation date
  fhir:PaymentReconciliation.organization [ Reference(Organization) ]; # 0..1 Insurer
  fhir:PaymentReconciliation.request [ Reference(ProcessRequest) ]; # 0..1 Claim reference
  fhir:PaymentReconciliation.outcome [ CodeableConcept ]; # 0..1 complete | error | partial
  fhir:PaymentReconciliation.disposition [ string ]; # 0..1 Disposition Message
  fhir:PaymentReconciliation.requestProvider [ Reference(Practitioner) ]; # 0..1 Responsible practitioner
  fhir:PaymentReconciliation.requestOrganization [ Reference(Organization) ]; # 0..1 Responsible organization
  fhir:PaymentReconciliation.detail [ # 0..* Details
    fhir:PaymentReconciliation.detail.type [ CodeableConcept ]; # 1..1 Type code
    fhir:PaymentReconciliation.detail.request [ Reference(Any) ]; # 0..1 Claim
    fhir:PaymentReconciliation.detail.response [ Reference(Any) ]; # 0..1 Claim Response
    fhir:PaymentReconciliation.detail.submitter [ Reference(Organization) ]; # 0..1 Submitter
    fhir:PaymentReconciliation.detail.payee [ Reference(Organization) ]; # 0..1 Payee
    fhir:PaymentReconciliation.detail.date [ date ]; # 0..1 Invoice date
    fhir:PaymentReconciliation.detail.amount [ Money ]; # 0..1 Detail amount
  ], ...;
  fhir:PaymentReconciliation.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:PaymentReconciliation.total [ Money ]; # 0..1 Total amount of Payment
  fhir:PaymentReconciliation.note [ # 0..* Note text
    fhir:PaymentReconciliation.note.type [ CodeableConcept ]; # 0..1 display | print | printoper
    fhir:PaymentReconciliation.note.text [ string ]; # 0..1 Notes text
  ], ...;
]

Changes since DSTU2

PaymentReconciliation
PaymentReconciliation.status added Element
PaymentReconciliation.outcome Type changed from code to CodeableConcept
PaymentReconciliation.detail.type Type changed from Coding to CodeableConcept
PaymentReconciliation.detail.response added Element
PaymentReconciliation.detail.amount Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
PaymentReconciliation.form Type changed from Coding to CodeableConcept
PaymentReconciliation.total Min Cardinality changed from 1 to 0
Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
PaymentReconciliation.note.type Type changed from Coding to CodeableConcept
PaymentReconciliation.ruleset deleted
PaymentReconciliation.originalRuleset deleted
PaymentReconciliation.detail.responce deleted

See the Full Difference for further information

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. PaymentReconciliation DomainResourcePaymentReconciliation resource
... identifier 0..*IdentifierBusiness Identifier
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... period 0..1PeriodPeriod covered
... created 0..1dateTimeCreation date
... organization 0..1Reference(Organization)Insurer
... request 0..1Reference(ProcessRequest)Claim reference
... outcome 0..1CodeableConceptcomplete | error | partial
RemittanceOutcome (Required)
... disposition 0..1stringDisposition Message
... requestProvider 0..1Reference(Practitioner)Responsible practitioner
... requestOrganization 0..1Reference(Organization)Responsible organization
... detail 0..*BackboneElementDetails
.... type 1..1CodeableConceptType code
Payment Type Codes (Example)
.... request 0..1Reference(Any)Claim
.... response 0..1Reference(Any)Claim Response
.... submitter 0..1Reference(Organization)Submitter
.... payee 0..1Reference(Organization)Payee
.... date 0..1dateInvoice date
.... amount 0..1MoneyDetail amount
... form 0..1CodeableConceptPrinted Form Identifier
Form Codes (Required)
... total 0..1MoneyTotal amount of Payment
... note 0..*BackboneElementNote text
.... type 0..1CodeableConceptdisplay | print | printoper
NoteType (Required)
.... text 0..1stringNotes text

doco Documentation for this format

UML Diagram (Legend)

PaymentReconciliation (DomainResource)The Response business identifieridentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [0..1] « A code specifying the state of the resource instance. (Strength=Required)Financial Resource Status ! »The period of time for which payments have been gathered into this bulk payment for settlementperiod : Period [0..1]The date when the enclosed suite of services were performed or completedcreated : dateTime [0..1]The Insurer who produced this adjudicated responseorganization : Reference [0..1] « Organization »Original request resource referencerequest : Reference [0..1] « ProcessRequest »Transaction status: error, completeoutcome : CodeableConcept [0..1] « The outcome of the processing. (Strength=Required)RemittanceOutcome! »A description of the status of the adjudicationdisposition : string [0..1]The practitioner who is responsible for the services rendered to the patientrequestProvider : Reference [0..1] « Practitioner »The organization which is responsible for the services rendered to the patientrequestOrganization : Reference [0..1] « Organization »The form to be used for printing the contentform : CodeableConcept [0..1] « The forms codes. (Strength=Required)Form ! »Total payment amounttotal : Money [0..1]DetailsCode to indicate the nature of the payment, adjustment, funds advance, etctype : CodeableConcept [1..1] « The reason for the amount: payment, adjustment, advance. (Strength=Example)Payment Type ?? »The claim or financial resourcerequest : Reference [0..1] « Any »The claim response resourceresponse : Reference [0..1] « Any »The Organization which submitted the invoice or financial transactionsubmitter : Reference [0..1] « Organization »The organization which is receiving the paymentpayee : Reference [0..1] « Organization »The date of the invoice or financial resourcedate : date [0..1]Amount paid for this detailamount : Money [0..1]NotesThe note purpose: Print/Displaytype : CodeableConcept [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>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <period><!-- 0..1 Period Period covered --></period>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <organization><!-- 0..1 Reference(Organization) Insurer --></organization>
 <request><!-- 0..1 Reference(ProcessRequest) Claim reference --></request>
 <outcome><!-- 0..1 CodeableConcept complete | error | partial --></outcome>
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
 <detail>  <!-- 0..* Details -->
  <type><!-- 1..1 CodeableConcept Type code --></type>
  <request><!-- 0..1 Reference(Any) Claim --></request>
  <response><!-- 0..1 Reference(Any) Claim Response --></response>
  <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 CodeableConcept Printed Form Identifier --></form>
 <total><!-- 0..1 Money Total amount of Payment --></total>
 <note>  <!-- 0..* Note text -->
  <type><!-- 0..1 CodeableConcept display | print | printoper --></type>
  <text value="[string]"/><!-- 0..1 Notes text -->
 </note>
</PaymentReconciliation>

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:PaymentReconciliation;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:PaymentReconciliation.identifier [ Identifier ], ... ; # 0..* Business Identifier
  fhir:PaymentReconciliation.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:PaymentReconciliation.period [ Period ]; # 0..1 Period covered
  fhir:PaymentReconciliation.created [ dateTime ]; # 0..1 Creation date
  fhir:PaymentReconciliation.organization [ Reference(Organization) ]; # 0..1 Insurer
  fhir:PaymentReconciliation.request [ Reference(ProcessRequest) ]; # 0..1 Claim reference
  fhir:PaymentReconciliation.outcome [ CodeableConcept ]; # 0..1 complete | error | partial
  fhir:PaymentReconciliation.disposition [ string ]; # 0..1 Disposition Message
  fhir:PaymentReconciliation.requestProvider [ Reference(Practitioner) ]; # 0..1 Responsible practitioner
  fhir:PaymentReconciliation.requestOrganization [ Reference(Organization) ]; # 0..1 Responsible organization
  fhir:PaymentReconciliation.detail [ # 0..* Details
    fhir:PaymentReconciliation.detail.type [ CodeableConcept ]; # 1..1 Type code
    fhir:PaymentReconciliation.detail.request [ Reference(Any) ]; # 0..1 Claim
    fhir:PaymentReconciliation.detail.response [ Reference(Any) ]; # 0..1 Claim Response
    fhir:PaymentReconciliation.detail.submitter [ Reference(Organization) ]; # 0..1 Submitter
    fhir:PaymentReconciliation.detail.payee [ Reference(Organization) ]; # 0..1 Payee
    fhir:PaymentReconciliation.detail.date [ date ]; # 0..1 Invoice date
    fhir:PaymentReconciliation.detail.amount [ Money ]; # 0..1 Detail amount
  ], ...;
  fhir:PaymentReconciliation.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:PaymentReconciliation.total [ Money ]; # 0..1 Total amount of Payment
  fhir:PaymentReconciliation.note [ # 0..* Note text
    fhir:PaymentReconciliation.note.type [ CodeableConcept ]; # 0..1 display | print | printoper
    fhir:PaymentReconciliation.note.text [ string ]; # 0..1 Notes text
  ], ...;
]

Changes since DSTU2

PaymentReconciliation
PaymentReconciliation.status added Element
PaymentReconciliation.outcome Type changed from code to CodeableConcept
PaymentReconciliation.detail.type Type changed from Coding to CodeableConcept
PaymentReconciliation.detail.response added Element
PaymentReconciliation.detail.amount Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
PaymentReconciliation.form Type changed from Coding to CodeableConcept
PaymentReconciliation.total Min Cardinality changed from 1 to 0
Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
PaymentReconciliation.note.type Type changed from Coding to CodeableConcept
PaymentReconciliation.ruleset deleted
PaymentReconciliation.originalRuleset deleted
PaymentReconciliation.detail.responce deleted

See the Full Difference for further information

 

Alternate definitions: Master Definition (XML, JSON), XML Schema/Schematron (for ) + JSON Schema, ShEx (for Turtle), JSON-LD (for RDF as JSON-LD),

13.10.2.1 Terminology Bindings

PathDefinitionTypeReference
PaymentReconciliation.status A code specifying the state of the resource instance.RequiredFinancial Resource Status Codes
PaymentReconciliation.outcome The outcome of the processing.RequiredRemittanceOutcome
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

13.10.3 Search Parameters

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

NameTypeDescriptionPathsIn Common
createddateThe creation datePaymentReconciliation.created
dispositionstringThe contents of the disposition messagePaymentReconciliation.disposition
identifiertokenThe business identifier of the Explanation of BenefitPaymentReconciliation.identifier
organizationreferenceThe organization who generated this resourcePaymentReconciliation.organization
(Organization)
outcometokenThe processing outcomePaymentReconciliation.outcome
requestreferenceThe reference to the claimPaymentReconciliation.request
(ProcessRequest)
request-organizationreferenceThe organization who generated this resourcePaymentReconciliation.requestOrganization
(Organization)
request-providerreferenceThe reference to the provider who sumbitted the claimPaymentReconciliation.requestProvider
(Practitioner)