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type: resourceresource: PaymentReconciliation

PaymentReconciliation

Introduction

Scope and Usage

The PaymentReconciliation resource provides the bulk payment details associated with a payment by the payor for receivable amounts, such as 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 may align to the individual payment amounts indicated on discrete ClaimResponses or Invoices for example.

Bulk payments need to provide a means to associate the amounts paid against specific Claims, Invoices, and other financial exchanges and adjustments, to the bulk payment itself in order to reconcile accounts receivable.

The PaymentReconciliation resource is a "event" resource from a FHIR workflow perspective - see Workflow Event.

Additional Information

Additional information regarding electronic payment notice content and usage may be found at:

Boundaries and Relationships

The PaymentReconciliation resource serves to correlate a payment amount to the adjudicated claim amounts appearing on one or more ClaimResponses. PaymentReconciliation 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.

The PaymentNotice resource is used to indicate that a payment has, or is about to occur. The resource is used commonly when tracking of payment occurences is required for regulatory or business purposes.

The ClaimResponse resource is an insurer's adjudication and/or authorization of a set of healthcare-related goods and services for a patient against the patient's insurance coverages and does not indicate that payment has occured.

For reporting out to patients or transferring data to patient centered applications, such as patient health Record (PHR) application, the ExplanationOfBenefit should be used instead.

The eClaim domain includes a number of related resources

PaymentReconciliationProvides 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.
ClaimResponseA payor's adjudication and/or authorization response to the suite of services provided in a Claim. Typically the ClaimResponse references the Claim but does not duplicate the clinical or financial information provided in the claim.
ExplanationOfBenefitThis resource combines the information from the Claim and the ClaimResponse, stripping out any provider or payor proprietary information, into a unified information model suitable for use for: patient reporting; transferring information to a Patient Health Record system; and, supporting complete claim and adjudication information exchange with regulatory and analytics organizations and other parts of the provider's organization.
PaymentNoticeAn indication that a payment has occured, is about to occur, or has been cancelled.

Background and Context

Provides additional detail on exactly how the resource is to be used

StructureDefinition

Elements (Simplified)

Mappings

Resource Packs

list-PaymentReconciliation-packs.xml

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

<List xmlns="http://hl7.org/fhir" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://hl7.org/fhir ../../publish/List.xsd">
  <id value="PaymentReconciliation-packs"/>
  <status value="current"/>
  <mode value="working"/>
</List>

Search Parameters

Full Search Parameters

Examples

Full Examples

Mapping Exceptions

paymentreconciliation-event-mapping-exceptions.xml

Divergent Elements

Unknown does not represent "other" - one of the defined statuses must apply. Unknown is used when the authoring system is not sure what the current status is. | resource=This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Unmapped Elements

paymentreconciliation-fivews-mapping-exceptions.xml

Unmapped Elements