R4 Ballot #1 (Mixed Normative/Trial use)

This page is part of the FHIR Specification (v3.3.0: R4 Ballot 2). 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

13.9 Resource PaymentReconciliation - Content

Financial Management

Work Group

Maturity Level: 2

Trial Use

Compartments: Practitioner

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

13.9.1 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.

Structure

Name	Flags	Card.	Type	Description & Constraints
PaymentReconciliation	TU		DomainResource	PaymentReconciliation resource Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
identifier		0..*	Identifier	Business Identifier
status	?!Σ	0..1	code	active \| cancelled \| draft \| entered-in-error Financial Resource Status Codes (Required)
period		0..1	Period	Period covered
created		0..1	dateTime	Creation date
organization		0..1	Reference(Organization)	Insurer
request		0..1	Reference(ProcessRequest)	Claim reference
outcome		0..1	code	queued \| complete \| error \| partial RemittanceOutcome (Required)
disposition		0..1	string	Disposition Message
requestProvider		0..1	Reference(Practitioner \| PractitionerRole \| Organization)	Responsible practitioner
detail		0..*	BackboneElement	List of settlements
type		1..1	CodeableConcept	Type code Payment Type Codes (Example)
request		0..1	Reference(Any)	Claim
response		0..1	Reference(Any)	Claim Response
submitter		0..1	Reference(Organization)	Organization which submitted the claim
payee		0..1	Reference(Organization)	Organization which is receiving the payment
date		0..1	date	Invoice date
amount		0..1	Money	Amount being paid
form		0..1	CodeableConcept	Printed Form Identifier Form Codes (Example)
total		0..1	Money	Total amount of Payment
processNote		0..*	BackboneElement	Processing comments
type		0..1	code	display \| print \| printoper NoteType (Required)
text		0..1	string	Comment on the processing
Documentation for this format

UML Diagram (Legend)

XML Template

<PaymentReconciliation xmlns="http://hl7.org/fhir"> 
 <!-- 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 value="[code]"/><!-- 0..1 queued | complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <requestProvider><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Responsible practitioner --></requestProvider>
 <detail>  <!-- 0..* List of settlements -->
  <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) Organization which submitted the claim --></submitter>
  <payee><!-- 0..1 Reference(Organization) Organization which is receiving the payment --></payee>
  <date value="[date]"/><!-- 0..1 Invoice date -->
  <amount><!-- 0..1 Money Amount being paid --></amount>
 </detail>
 <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form>
 <total><!-- 0..1 Money Total amount of Payment --></total>
 <processNote>  <!-- 0..* Processing comments -->
  <type value="[code]"/><!-- 0..1 display | print | printoper -->
  <text value="[string]"/><!-- 0..1 Comment on the processing -->
 </processNote>
</PaymentReconciliation>

JSON Template

{
  "resourceType" : "PaymentReconciliation",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "period" : { Period }, // Period covered
  "created" : "<dateTime>", // Creation date
  "organization" : { Reference(Organization) }, // Insurer
  "request" : { Reference(ProcessRequest) }, // Claim reference
  "outcome" : "<code>", // queued | complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "requestProvider" : { Reference(Practitioner|PractitionerRole|Organization) }, // Responsible practitioner
  "detail" : [{ // List of settlements
    "type" : { CodeableConcept }, // R!  Type code
    "request" : { Reference(Any) }, // Claim
    "response" : { Reference(Any) }, // Claim Response
    "submitter" : { Reference(Organization) }, // Organization which submitted the claim
    "payee" : { Reference(Organization) }, // Organization which is receiving the payment
    "date" : "<date>", // Invoice date
    "amount" : { Money } // Amount being paid
  }],
  "form" : { CodeableConcept }, // Printed Form Identifier
  "total" : { Money }, // Total amount of Payment
  "processNote" : [{ // Processing comments
    "type" : "<code>", // display | print | printoper
    "text" : "<string>" // Comment on the processing
  }]
}

Turtle Template

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


[ 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 [ code ]; # 0..1 queued | complete | error | partial
  fhir:PaymentReconciliation.disposition [ string ]; # 0..1 Disposition Message
  fhir:PaymentReconciliation.requestProvider [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Responsible practitioner
  fhir:PaymentReconciliation.detail [ # 0..* List of settlements
    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 Organization which submitted the claim
    fhir:PaymentReconciliation.detail.payee [ Reference(Organization) ]; # 0..1 Organization which is receiving the payment
    fhir:PaymentReconciliation.detail.date [ date ]; # 0..1 Invoice date
    fhir:PaymentReconciliation.detail.amount [ Money ]; # 0..1 Amount being paid
  ], ...;
  fhir:PaymentReconciliation.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:PaymentReconciliation.total [ Money ]; # 0..1 Total amount of Payment
  fhir:PaymentReconciliation.processNote [ # 0..* Processing comments
    fhir:PaymentReconciliation.processNote.type [ code ]; # 0..1 display | print | printoper
    fhir:PaymentReconciliation.processNote.text [ string ]; # 0..1 Comment on the processing
  ], ...;
]

Changes since R3

PaymentReconciliation

PaymentReconciliation.outcome

Type changed from CodeableConcept to code

PaymentReconciliation.requestProvider

Type changed from Reference(Practitioner) to Reference(Practitioner|PractitionerRole|Organization)

PaymentReconciliation.processNote.type

Type changed from CodeableConcept to code

PaymentReconciliation.requestOrganization

deleted

See the Full Difference for further information

This analysis is available as XML or JSON.

Structure

Name	Flags	Card.	Type	Description & Constraints
PaymentReconciliation	TU		DomainResource	PaymentReconciliation resource Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
identifier		0..*	Identifier	Business Identifier
status	?!Σ	0..1	code	active \| cancelled \| draft \| entered-in-error Financial Resource Status Codes (Required)
period		0..1	Period	Period covered
created		0..1	dateTime	Creation date
organization		0..1	Reference(Organization)	Insurer
request		0..1	Reference(ProcessRequest)	Claim reference
outcome		0..1	code	queued \| complete \| error \| partial RemittanceOutcome (Required)
disposition		0..1	string	Disposition Message
requestProvider		0..1	Reference(Practitioner \| PractitionerRole \| Organization)	Responsible practitioner
detail		0..*	BackboneElement	List of settlements
type		1..1	CodeableConcept	Type code Payment Type Codes (Example)
request		0..1	Reference(Any)	Claim
response		0..1	Reference(Any)	Claim Response
submitter		0..1	Reference(Organization)	Organization which submitted the claim
payee		0..1	Reference(Organization)	Organization which is receiving the payment
date		0..1	date	Invoice date
amount		0..1	Money	Amount being paid
form		0..1	CodeableConcept	Printed Form Identifier Form Codes (Example)
total		0..1	Money	Total amount of Payment
processNote		0..*	BackboneElement	Processing comments
type		0..1	code	display \| print \| printoper NoteType (Required)
text		0..1	string	Comment on the processing
Documentation for this format

UML Diagram (Legend)

XML Template

<PaymentReconciliation xmlns="http://hl7.org/fhir"> 
 <!-- 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 value="[code]"/><!-- 0..1 queued | complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <requestProvider><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Responsible practitioner --></requestProvider>
 <detail>  <!-- 0..* List of settlements -->
  <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) Organization which submitted the claim --></submitter>
  <payee><!-- 0..1 Reference(Organization) Organization which is receiving the payment --></payee>
  <date value="[date]"/><!-- 0..1 Invoice date -->
  <amount><!-- 0..1 Money Amount being paid --></amount>
 </detail>
 <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form>
 <total><!-- 0..1 Money Total amount of Payment --></total>
 <processNote>  <!-- 0..* Processing comments -->
  <type value="[code]"/><!-- 0..1 display | print | printoper -->
  <text value="[string]"/><!-- 0..1 Comment on the processing -->
 </processNote>
</PaymentReconciliation>

JSON Template

{
  "resourceType" : "PaymentReconciliation",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "period" : { Period }, // Period covered
  "created" : "<dateTime>", // Creation date
  "organization" : { Reference(Organization) }, // Insurer
  "request" : { Reference(ProcessRequest) }, // Claim reference
  "outcome" : "<code>", // queued | complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "requestProvider" : { Reference(Practitioner|PractitionerRole|Organization) }, // Responsible practitioner
  "detail" : [{ // List of settlements
    "type" : { CodeableConcept }, // R!  Type code
    "request" : { Reference(Any) }, // Claim
    "response" : { Reference(Any) }, // Claim Response
    "submitter" : { Reference(Organization) }, // Organization which submitted the claim
    "payee" : { Reference(Organization) }, // Organization which is receiving the payment
    "date" : "<date>", // Invoice date
    "amount" : { Money } // Amount being paid
  }],
  "form" : { CodeableConcept }, // Printed Form Identifier
  "total" : { Money }, // Total amount of Payment
  "processNote" : [{ // Processing comments
    "type" : "<code>", // display | print | printoper
    "text" : "<string>" // Comment on the processing
  }]
}

Turtle Template

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


[ 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 [ code ]; # 0..1 queued | complete | error | partial
  fhir:PaymentReconciliation.disposition [ string ]; # 0..1 Disposition Message
  fhir:PaymentReconciliation.requestProvider [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Responsible practitioner
  fhir:PaymentReconciliation.detail [ # 0..* List of settlements
    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 Organization which submitted the claim
    fhir:PaymentReconciliation.detail.payee [ Reference(Organization) ]; # 0..1 Organization which is receiving the payment
    fhir:PaymentReconciliation.detail.date [ date ]; # 0..1 Invoice date
    fhir:PaymentReconciliation.detail.amount [ Money ]; # 0..1 Amount being paid
  ], ...;
  fhir:PaymentReconciliation.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:PaymentReconciliation.total [ Money ]; # 0..1 Total amount of Payment
  fhir:PaymentReconciliation.processNote [ # 0..* Processing comments
    fhir:PaymentReconciliation.processNote.type [ code ]; # 0..1 display | print | printoper
    fhir:PaymentReconciliation.processNote.text [ string ]; # 0..1 Comment on the processing
  ], ...;
]

Changes since DSTU2

PaymentReconciliation

PaymentReconciliation.outcome

Type changed from CodeableConcept to code

PaymentReconciliation.requestProvider

Type changed from Reference(Practitioner) to Reference(Practitioner|PractitionerRole|Organization)

PaymentReconciliation.processNote.type

Type changed from CodeableConcept to code

PaymentReconciliation.requestOrganization

deleted

See the Full Difference for further information

This analysis is available as XML or JSON.

Alternate definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions & the dependency analysis

13.9.2.1 Terminology Bindings

Path	Definition	Type	Reference
PaymentReconciliation.status	A code specifying the state of the resource instance.	Required	Financial Resource Status Codes
PaymentReconciliation.outcome	The outcome of the processing.	Required	RemittanceOutcome
PaymentReconciliation.detail.type	The reason for the amount: payment, adjustment, advance.	Example	Payment Type Codes
PaymentReconciliation.form	The forms codes.	Example	Form Codes
PaymentReconciliation.processNote.type	The presentation types of notes.	Required	NoteType

Path

Definition

Type

Reference

PaymentReconciliation.status

A code specifying the state of the resource instance.

Required

Financial Resource Status Codes

PaymentReconciliation.outcome

The outcome of the processing.

Required

RemittanceOutcome

PaymentReconciliation.detail.type

The reason for the amount: payment, adjustment, advance.

Example

Payment Type Codes

PaymentReconciliation.form

The forms codes.

Example

Form Codes

PaymentReconciliation.processNote.type

The presentation types of notes.

Required

NoteType

13.9.3 Search Parameters

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

Name	Type	Description	Expression	In Common
created	date	The creation date	PaymentReconciliation.created
disposition	string	The contents of the disposition message	PaymentReconciliation.disposition
identifier	token	The business identifier of the Explanation of Benefit	PaymentReconciliation.identifier
organization	reference	The organization who generated this resource	PaymentReconciliation.organization (Organization)
outcome	token	The processing outcome	PaymentReconciliation.outcome
request	reference	The reference to the claim	PaymentReconciliation.request (ProcessRequest)
request-provider	reference	The reference to the provider who sumbitted the claim	PaymentReconciliation.requestProvider (Practitioner, Organization, PractitionerRole)
status	token	The status of the payment reconciliation	PaymentReconciliation.status