General Payment Reconciliation Example

{
  "resourceType" : "PaymentReconciliation",
  "id" : "ER2500",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the PaymentReconciliation</div>"
  },
  "identifier" : [{
    "system" : "http://www.BenefitsInc.com/fhir/enrollmentresponse",
    "value" : "781234"
  }],
  "type" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/payment-type",
      "code" : "payment"
    }]
  },
  "status" : "active",
  "period" : {
    "start" : "2014-08-16",
    "end" : "2014-08-31"
  },
  "created" : "2014-08-16",
  "paymentIssuer" : {
    "reference" : "Organization/2"
  },
  "request" : {
    "reference" : "http://www.BenefitsInc.com/fhir/eligibility/225476332402"
  },
  "requestor" : {
    "reference" : "Organization/1"
  },
  "outcome" : "complete",
  "disposition" : "2014 August mid-month settlement.",
  "date" : "2014-08-01",
  "amount" : {
    "value" : 7000.00,
    "currency" : "USD"
  },
  "paymentIdentifier" : {
    "system" : "http://www.BenefitsInc.com/payment/2018",
    "value" : "10-12345"
  },
  "allocation" : [{
    "identifier" : {
      "system" : "http://www.BenefitsInc.com/payment/2018/detail",
      "value" : "10-12345-001"
    },
    "target" : {
      "identifier" : {
        "system" : "http://happyvalleyclinic.com/claim",
        "value" : "AB12345"
      }
    },
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/payment-type",
        "code" : "payment"
      }]
    },
    "submitter" : {
      "reference" : "Organization/1"
    },
    "response" : {
      "identifier" : {
        "system" : "http://www.BenefitsInc.com/fhir/claimresponse",
        "value" : "CR20140815-AB12345"
      }
    },
    "date" : "2014-08-16",
    "payee" : {
      "reference" : "Organization/1"
    },
    "amount" : {
      "value" : 3500.00,
      "currency" : "USD"
    }
  },
  {
    "identifier" : {
      "system" : "http://www.BenefitsInc.com/payment/2018/detail",
      "value" : "10-12345-002"
    },
    "target" : {
      "reference" : "http://www.BenefitsInc.com/fhir/oralhealthclaim/225476332699"
    },
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/payment-type",
        "code" : "payment"
      }]
    },
    "date" : "2014-08-12",
    "amount" : {
      "value" : 4000.00,
      "currency" : "USD"
    }
  },
  {
    "identifier" : {
      "system" : "http://www.BenefitsInc.com/payment/2018/detail",
      "value" : "10-12345-003"
    },
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/payment-type",
        "code" : "advance"
      }]
    },
    "date" : "2014-08-16",
    "amount" : {
      "value" : -1500.00,
      "currency" : "USD"
    }
  }],
  "formCode" : {
    "coding" : [{
      "system" : "http://ncforms.org/formid",
      "code" : "PAYREC/2016/01B"
    }]
  },
  "processNote" : [{
    "type" : "display",
    "text" : "Due to the year end holiday the cutoff for submissions for December will be the 28th."
  }]
}