--- type: "resource" title: "PaymentReconciliation" resource: "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](claimresponse) or [Invoices](invoice) 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.](workflow#event) ### Additional Information Additional information regarding electronic payment notice content and usage may be found at: - [Financial Resource Status Lifecycle](financial-module#resource-status): how .status is used in the financial resources. ## Boundaries and Relationships The PaymentReconciliation resource serves to correlate a payment amount to the adjudicated claim amounts appearing on one or more [ClaimResponses](claimresponse). 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](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](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](explanationofbenefit) should be used instead. **The eClaim domain includes a number of related resources** | 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. | | --- | --- | | [ClaimResponse](claimresponse) | A 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. | | [ExplanationOfBenefit](explanationofbenefit) | This 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. | | [PaymentNotice](paymentnotice) | An 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) - **[PaymentReconciliation](/paymentreconciliation-definitions#PaymentReconciliation)** [0..*]: - PaymentReconciliation resource - **[PaymentReconciliation.identifier](/paymentreconciliation-definitions#PaymentReconciliation.identifier)** [0..*]: [Identifier](/Identifier) Business Identifier for a payment reconciliation - **[PaymentReconciliation.type](/paymentreconciliation-definitions#PaymentReconciliation.type)** [1..1]: [CodeableConcept](/CodeableConcept) extensible:[payment-type](/valueset-payment-type) Category of payment - **[PaymentReconciliation.status](/paymentreconciliation-definitions#PaymentReconciliation.status)** [1..1]: [code](/code) required:[fm-status](/valueset-fm-status) active | cancelled | draft | entered-in-error - **[PaymentReconciliation.statusReason](/paymentreconciliation-definitions#PaymentReconciliation.statusReason)** [0..1]: [string](/string) Reason for status change - **[PaymentReconciliation.kind](/paymentreconciliation-definitions#PaymentReconciliation.kind)** [0..1]: [CodeableConcept](/CodeableConcept) extensible:[payment-kind](/valueset-payment-kind) Workflow originating payment - **[PaymentReconciliation.period](/paymentreconciliation-definitions#PaymentReconciliation.period)** [0..1]: [Period](/Period) Period covered - **[PaymentReconciliation.created](/paymentreconciliation-definitions#PaymentReconciliation.created)** [1..1]: [dateTime](/dateTime) Creation date - **[PaymentReconciliation.enterer](/paymentreconciliation-definitions#PaymentReconciliation.enterer)** [0..1]: [Reference(Practitioner](/Reference(Practitioner), [PractitionerRole](/PractitionerRole), [Organization)](/Organization)) Who entered the payment - **[PaymentReconciliation.issuerType](/paymentreconciliation-definitions#PaymentReconciliation.issuerType)** [0..1]: [CodeableConcept](/CodeableConcept) extensible:[payment-issuertype](/valueset-payment-issuertype) Nature of the source - **[PaymentReconciliation.paymentIssuer](/paymentreconciliation-definitions#PaymentReconciliation.paymentIssuer)** [0..1]: [Reference(Organization](/Reference(Organization), [Patient](/Patient), [RelatedPerson)](/RelatedPerson)) Party generating payment - **[PaymentReconciliation.request](/paymentreconciliation-definitions#PaymentReconciliation.request)** [0..1]: Reference([Task](/Task)) Reference to requesting resource - **[PaymentReconciliation.requestor](/paymentreconciliation-definitions#PaymentReconciliation.requestor)** [0..1]: [Reference(Practitioner](/Reference(Practitioner), [PractitionerRole](/PractitionerRole), [Organization)](/Organization)) Responsible practitioner - **[PaymentReconciliation.outcome](/paymentreconciliation-definitions#PaymentReconciliation.outcome)** [0..1]: [code](/code) required:[payment-outcome](/valueset-payment-outcome) queued | complete | error | partial - **[PaymentReconciliation.disposition](/paymentreconciliation-definitions#PaymentReconciliation.disposition)** [0..1]: [string](/string) Disposition message - **[PaymentReconciliation.date](/paymentreconciliation-definitions#PaymentReconciliation.date)** [1..1]: [date](/date) When payment issued - **[PaymentReconciliation.location](/paymentreconciliation-definitions#PaymentReconciliation.location)** [0..1]: Reference([Location](/Location)) Where payment collected - **[PaymentReconciliation.method](/paymentreconciliation-definitions#PaymentReconciliation.method)** [0..1]: [CodeableConcept](/CodeableConcept) extensible:[v2-0570](/valueset-v2-0570) Payment instrument - **[PaymentReconciliation.cardBrand](/paymentreconciliation-definitions#PaymentReconciliation.cardBrand)** [0..1]: [string](/string) Type of card - **[PaymentReconciliation.accountNumber](/paymentreconciliation-definitions#PaymentReconciliation.accountNumber)** [0..1]: [string](/string) Digits for verification - **[PaymentReconciliation.expirationDate](/paymentreconciliation-definitions#PaymentReconciliation.expirationDate)** [0..1]: [date](/date) Expiration year-month - **[PaymentReconciliation.processor](/paymentreconciliation-definitions#PaymentReconciliation.processor)** [0..1]: [string](/string) Processor name - **[PaymentReconciliation.referenceNumber](/paymentreconciliation-definitions#PaymentReconciliation.referenceNumber)** [0..1]: [string](/string) Check number or payment reference - **[PaymentReconciliation.authorization](/paymentreconciliation-definitions#PaymentReconciliation.authorization)** [0..1]: [string](/string) Authorization number - **[PaymentReconciliation.tenderedAmount](/paymentreconciliation-definitions#PaymentReconciliation.tenderedAmount)** [0..1]: [Money](/Money) Amount offered by the issuer - **[PaymentReconciliation.returnedAmount](/paymentreconciliation-definitions#PaymentReconciliation.returnedAmount)** [0..1]: [Money](/Money) Amount returned by the receiver - **[PaymentReconciliation.amount](/paymentreconciliation-definitions#PaymentReconciliation.amount)** [0..1]: [Money](/Money) Total amount of Payment - **[PaymentReconciliation.paymentIdentifier](/paymentreconciliation-definitions#PaymentReconciliation.paymentIdentifier)** [0..1]: [Identifier](/Identifier) Business identifier for the payment - **[PaymentReconciliation.allocation](/paymentreconciliation-definitions#PaymentReconciliation.allocation)** [0..*]: [BackboneElement](/BackboneElement) Settlement particulars - **[PaymentReconciliation.allocation.identifier](/paymentreconciliation-definitions#PaymentReconciliation.allocation.identifier)** [0..1]: [Identifier](/Identifier) Business identifier of the payment detail - **[PaymentReconciliation.allocation.predecessor](/paymentreconciliation-definitions#PaymentReconciliation.allocation.predecessor)** [0..1]: [Identifier](/Identifier) Business identifier of the prior payment detail - **[PaymentReconciliation.allocation.target](/paymentreconciliation-definitions#PaymentReconciliation.allocation.target)** [0..1]: [Reference(Claim](/Reference(Claim), [Account](/Account), [Invoice](/Invoice), [Encounter](/Encounter), [Contract)](/Contract)) Subject of the payment - **[PaymentReconciliation.allocation.targetItem[x]](/paymentreconciliation-definitions#PaymentReconciliation.allocation.targetItem%5Bx%5D)** [0..1]: [string](/string), [Identifier](/Identifier), [positiveInt](/positiveInt) Sub-element of the subject - **[PaymentReconciliation.allocation.encounter](/paymentreconciliation-definitions#PaymentReconciliation.allocation.encounter)** [0..1]: Reference([Encounter](/Encounter)) Applied-to encounter - **[PaymentReconciliation.allocation.account](/paymentreconciliation-definitions#PaymentReconciliation.allocation.account)** [0..1]: Reference([Account](/Account)) Applied-to account - **[PaymentReconciliation.allocation.type](/paymentreconciliation-definitions#PaymentReconciliation.allocation.type)** [0..1]: [CodeableConcept](/CodeableConcept) extensible:[payment-type](/valueset-payment-type) Category of payment - **[PaymentReconciliation.allocation.submitter](/paymentreconciliation-definitions#PaymentReconciliation.allocation.submitter)** [0..1]: [Reference(Practitioner](/Reference(Practitioner), [PractitionerRole](/PractitionerRole), [Organization)](/Organization)) Submitter of the request - **[PaymentReconciliation.allocation.response](/paymentreconciliation-definitions#PaymentReconciliation.allocation.response)** [0..1]: Reference([ClaimResponse](/ClaimResponse)) Response committing to a payment - **[PaymentReconciliation.allocation.date](/paymentreconciliation-definitions#PaymentReconciliation.allocation.date)** [0..1]: [date](/date) Date of commitment to pay - **[PaymentReconciliation.allocation.responsible](/paymentreconciliation-definitions#PaymentReconciliation.allocation.responsible)** [0..1]: Reference([PractitionerRole](/PractitionerRole)) Contact for the response - **[PaymentReconciliation.allocation.payee](/paymentreconciliation-definitions#PaymentReconciliation.allocation.payee)** [0..1]: [Reference(Practitioner](/Reference(Practitioner), [PractitionerRole](/PractitionerRole), [Organization)](/Organization)) Recipient of the payment - **[PaymentReconciliation.allocation.amount](/paymentreconciliation-definitions#PaymentReconciliation.allocation.amount)** [0..1]: [Money](/Money) Amount allocated to this payable - **[PaymentReconciliation.allocation.noteNumber](/paymentreconciliation-definitions#PaymentReconciliation.allocation.noteNumber)** [0..*]: [positiveInt](/positiveInt) Applicable note numbers - **[PaymentReconciliation.formCode](/paymentreconciliation-definitions#PaymentReconciliation.formCode)** [0..1]: [CodeableConcept](/CodeableConcept) example:[forms](/valueset-forms) Printed form identifier - **[PaymentReconciliation.processNote](/paymentreconciliation-definitions#PaymentReconciliation.processNote)** [0..*]: [BackboneElement](/BackboneElement) Note concerning processing - **[PaymentReconciliation.processNote.class](/paymentreconciliation-definitions#PaymentReconciliation.processNote.class)** [0..1]: [CodeableConcept](/CodeableConcept) Business kind of note - **[PaymentReconciliation.processNote.number](/paymentreconciliation-definitions#PaymentReconciliation.processNote.number)** [0..1]: [positiveInt](/positiveInt) Note instance identifier - **[PaymentReconciliation.processNote.type](/paymentreconciliation-definitions#PaymentReconciliation.processNote.type)** [0..1]: [code](/code) required:[note-type](/valueset-note-type) display | print | printoper - **[PaymentReconciliation.processNote.text](/paymentreconciliation-definitions#PaymentReconciliation.processNote.text)** [0..1]: [markdown](/markdown) Note explanatory text ## Mappings - [PaymentReconciliation Mappings](/paymentreconciliation-mappings) — 16 mapping entries ## Resource Packs ### list-PaymentReconciliation-packs.xml ```xml ``` ## Search Parameters - [created](/paymentreconciliation-search#created) — **date** — The creation date — `PaymentReconciliation.created` - [disposition](/paymentreconciliation-search#disposition) — **string** — The contents of the disposition message — `PaymentReconciliation.disposition` - [identifier](/paymentreconciliation-search#identifier) — **token** — The business identifier of the ExplanationOfBenefit — `PaymentReconciliation.identifier` - [outcome](/paymentreconciliation-search#outcome) — **token** — The processing outcome — `PaymentReconciliation.outcome` - [payment-issuer](/paymentreconciliation-search#payment-issuer) — **reference** — The organization which generated this resource — `PaymentReconciliation.paymentIssuer` - [request](/paymentreconciliation-search#request) — **reference** — The reference to the claim — `PaymentReconciliation.request` - [requestor](/paymentreconciliation-search#requestor) — **reference** — The reference to the provider who submitted the claim — `PaymentReconciliation.requestor` - [status](/paymentreconciliation-search#status) — **token** — The status of the payment reconciliation — `PaymentReconciliation.status` - [allocation-encounter](/paymentreconciliation-search#allocation-encounter) — **reference** — The encounter to which payment or adjustment was applied. — `PaymentReconciliation.allocation.encounter` - [allocation-account](/paymentreconciliation-search#allocation-account) — **reference** — The account to which payment or adjustment was applied. — `PaymentReconciliation.allocation.account` [Full Search Parameters](/paymentreconciliation-search) ## Examples - [ER2500](/paymentreconciliation-example-ER2500) — paymentreconciliation-example — General Payment Reconciliation Example - [paymentreconciliation-example](/paymentreconciliation-example-paymentreconciliation-example) — paymentreconciliation-example - [paymentreconciliation-examples-header](/paymentreconciliation-example-paymentreconciliation-examples-header) — paymentreconciliation-examples-header [Full Examples](/paymentreconciliation-examples) ## Mapping Exceptions ### paymentreconciliation-event-mapping-exceptions.xml ### Divergent Elements - **Event.identifier** → **PaymentReconciliation.identifier** - summary | reason=Unknown | pattern=true - shortUnmatched | reason=Unknown | pattern=Business identifier for payment reconciliation | resource=Business Identifier for a payment reconciliation - definitionUnmatched | reason=Unknown | pattern=Business identifiers assigned to this payment reconciliation by the performer and/or other systems. These identifiers remain constant as the resource is updated and propagates from server to server. | resource=A unique identifier assigned to this payment reconciliation. - commentsUnmatched | reason=Unknown | pattern=Note: This is a business identifier, not a resource identifier (see [discussion](resource.html#identifiers)). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number. - requirementsUnmatched | reason=Unknown | pattern=Allows identification of the payment reconciliation as it is known by various participating systems and in a way that remains consistent across servers. | resource=Allows payment reconciliations to be distinguished and referenced. - **Event.status** → **PaymentReconciliation.status** - shortUnmatched | reason=Unknown | pattern=preparation | in-progress | not-done | suspended | aborted | completed | entered-in-error | unknown | resource=active | cancelled | draft | entered-in-error - definitionUnmatched | reason=Unknown | pattern=The current state of the payment reconciliation. | resource=The status of the resource instance. - commentsUnmatched | reason=Unknown | pattern=A nominal state-transition diagram can be found in the (Event pattern documentation 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. - **Event.occurrence[x]** → **PaymentReconciliation.created** - missingTypes | reason=Unknown | pattern=Period, Timing - shortUnmatched | reason=Unknown | pattern=When payment reconciliation occurred/is occurring | resource=Creation date - definitionUnmatched | reason=Unknown | pattern=The date, period or timing when the payment reconciliation did occur or is occurring. | resource=The date when the resource was created. - commentsUnmatched | reason=Unknown | pattern=This indicates when the activity actually occurred or is occurring, not when it was asked/requested/ordered to occur. For the latter, look at the occurence element of the Request this {{event}} is "basedOn". The status code allows differentiation of whether the timing reflects a historic event or an ongoing event. Ongoing events should not include an upper bound in the Period or Timing.bounds. . - **Event.performer.actor** → **PaymentReconciliation.paymentIssuer** - missingTypes | reason=Unknown | pattern=Reference(Practitioner, PractitionerRole, CareTeam, Device) - shortUnmatched | reason=Unknown | pattern=Who performed payment reconciliation | resource=Party generating payment - definitionUnmatched | reason=Unknown | pattern=Indicates who or what performed the payment reconciliation. | resource=The party who generated the payment. - **Event.note** → **PaymentReconciliation.disposition** - missingTypes | reason=Unknown | pattern=Annotation - extraTypes | reason=Unknown - shortUnmatched | reason=Unknown | pattern=Comments made about the event | resource=Disposition message - definitionUnmatched | reason=Unknown | pattern=Comments made about the payment reconciliation by the performer, subject or other participants. | resource=A human readable description of the status of the request for the reconciliation. ### Unmapped Elements - **Event.partOf** — Unknown - **Event.reported** — Unknown - **Event.reason** — Unknown - **Event.relevantHistory** — Unknown - **Event.code** — Unknown - **Event.location** — Unknown - **Event.subject** — Unknown - **Event.statusReason** — Unknown - **Event.performer.function** — Unknown - **Event.category** — Unknown - **Event.encounter** — Unknown - **Event.recorded** — Unknown - **Event.product** — Unknown - **Event.performer** — Unknown - **Event.researchStudy** — Unknown ### paymentreconciliation-fivews-mapping-exceptions.xml ### Unmapped Elements - **FiveWs.what** — Unknown - **FiveWs.author** — Unknown - **FiveWs.actor** — Unknown - **FiveWs.cause** — Unknown - **FiveWs.version** — Unknown - **FiveWs.witness** — Unknown - **FiveWs.class** — Unknown - **FiveWs.where** — Unknown - **FiveWs.context** — Unknown - **FiveWs.init** — Unknown - **FiveWs.who** — Unknown - **FiveWs.grade** — Unknown - **FiveWs.planned** — Unknown - **FiveWs.subject** — Unknown