Paymentreconciliation-example.json

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"
    }
  ],
  "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.",
  "paymentDate": "2014-08-01",
  "paymentAmount": {
    "value": 7000.00,
    "currency": "USD"
  },
  "paymentIdentifier": {
    "system": "http://www.BenefitsInc.com/payment/2018",
    "value": "10-12345"
  },
  "detail": [
    {
      "identifier": {
        "system": "http://www.BenefitsInc.com/payment/2018/detail",
        "value": "10-12345-001"
      },
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/payment-type",
            "code": "payment"
          }
        ]
      },
      "request": {
        "identifier": {
          "system": "http://happyvalleyclinic.com/claim",
          "value": "AB12345"
        }
      },
      "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"
      },
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/payment-type",
            "code": "payment"
          }
        ]
      },
      "request": {
        "reference": "http://www.BenefitsInc.com/fhir/oralhealthclaim/225476332699"
      },
      "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."
    }
  ]
}