PaymentReconciliation Example: paymentreconciliation-example

Narrative

A human-readable rendering of the PaymentReconciliation

Example XML

<PaymentReconciliation xmlns="http://hl7.org/fhir" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://hl7.org/fhir ../../schema/remittance.xsd">
    <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>

    <type>
        <coding>
            <system value="http://terminology.hl7.org/CodeSystem/payment-type"/>
            <code value="payment"/>
        </coding>
    </type>

    <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."/>

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

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

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

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

        <target>
            <identifier>
                <system value="http://happyvalleyclinic.com/claim"/>
                <value value="AB12345"/>
            </identifier>
        </target>

        <type>
            <coding>
                <system value="http://terminology.hl7.org/CodeSystem/payment-type"/>
                <code value="payment"/>
            </coding>
        </type>

        <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>   
    </allocation>

    <allocation>
        <identifier>
            <system value="http://www.BenefitsInc.com/payment/2018/detail"/>
            <value value="10-12345-002"/>
        </identifier>

        <target>
            <reference value="http://www.BenefitsInc.com/fhir/oralhealthclaim/225476332699"/>
        </target>

        <type>
            <coding>
                <system value="http://terminology.hl7.org/CodeSystem/payment-type"/>
                <code value="payment"/>
            </coding>
        </type>

        <date value="2014-08-12"/>
        <amount>
            <value value="4000.00"/>
            <currency value="USD"/>
        </amount>   
    </allocation>

    <allocation>
        <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>   
    </allocation>

    <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>