---
type: "example"
title: "PaymentReconciliation Example: paymentreconciliation-example"
resource: "PaymentReconciliation"
example: "paymentreconciliation-example"
---
# PaymentReconciliation Example: paymentreconciliation-example

## Narrative

A human-readable rendering of the PaymentReconciliation

## Example XML



```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>
```