Paymentreconciliation-example.xml

General Payment Reconciliation Example (id = "ER2500")

<?xml version="1.0" encoding="UTF-8"?>

<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"/> 

  <period> 
    <start value="2014-08-16"/> 
    <end value="2014-08-31"/> 
  </period> 

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

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

  <request> 
    <reference value="http://www.BenefitsInc.com/fhir/eligibility/225476332402"/> 
  </request> 

  <requestor> 
    <reference value="Organization/1"/> 
  </requestor> 

  <outcome value="complete"/> 

  <disposition value="2014 August mid-month settlement."/> 

  <paymentDate value="2014-08-01"/> 

  <paymentAmount> 
    <value value="7000.00"/> 
    <currency value="USD"/> 
  </paymentAmount> 

  <paymentIdentifier> 
    <system value="http://www.BenefitsInc.com/payment/2018"/> 
    <value value="10-12345"/> 
  </paymentIdentifier> 

  <detail> 
    <identifier> 
      <system value="http://www.BenefitsInc.com/payment/2018/detail"/> 
      <value value="10-12345-001"/> 
    </identifier> 

    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/payment-type"/> 
        <code value="payment"/> 
      </coding> 
    </type> 
    <request> 
      <identifier> 
        <system value="http://happyvalleyclinic.com/claim"/> 
        <value value="AB12345"/> 
      </identifier> 
    </request> 
    <submitter> 
      <reference value="Organization/1"/> 
    </submitter> 
    <response> 
      <identifier> 
        <system value="http://www.BenefitsInc.com/fhir/claimresponse"/> 
        <value value="CR20140815-AB12345"/> 
      </identifier>   
    </response> 
    <date value="2014-08-16"/> 
    <payee> 
      <reference value="Organization/1"/> 
    </payee> 
    <amount> 
      <value value="3500.00"/> 
      <currency value="USD"/> 
    </amount>    
  </detail> 

  <detail> 
    <identifier> 
      <system value="http://www.BenefitsInc.com/payment/2018/detail"/> 
      <value value="10-12345-002"/> 
    </identifier> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/payment-type"/> 
        <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"/> 
      <currency value="USD"/> 
    </amount>    
  </detail> 

  <detail> 
    <identifier> 
      <system value="http://www.BenefitsInc.com/payment/2018/detail"/> 
      <value value="10-12345-003"/> 
    </identifier> 
    <type> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/payment-type"/> 
        <code value="advance"/> 
      </coding> 
    </type> 
    <date value="2014-08-16"/> 
    <amount> 
      <value value="-1500.00"/> 
      <currency value="USD"/> 
    </amount>    
  </detail> 

  <formCode> 
    <coding> 
      <system value="http://ncforms.org/formid"/> 
      <code value="PAYREC/2016/01B"/> 
    </coding> 
  </formCode> 

  <processNote> 
    <type value="display"/> 
    <text value="Due to the year end holiday the cutoff for submissions for December will be the 28th."/> 
  </processNote> 

</PaymentReconciliation>