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This page is part of the FHIR Specification (v4.3.0: R4B (v5.0.0: R5 - STU ). The This is the current published version which supercedes in it's permanent home (it will always be available at this version is 5.0.0 . URL). For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R5 R4B R4 R3 R2

Paymentreconciliation-example.xml

Example PaymentReconciliation/ER2500 (XML)

Financial Management Work Group Maturity Level : N/A Standards Status : Informative Compartments : Practitioner

Raw XML ( canonical form + also see XML Format Specification )

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General Payment Reconciliation Example (id = "ER2500") 

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


  

  
    
    
  

  
    
    
  

  

  
    
    
  

  

  
    
  

  
    
  

  
    
  

  

  

  

  
    
    
  

  
    
    
  

  
    
      
      
    

    
      
        
        
      
    
    
      
        
        
      
    
    
      
    
    
      
        
        
        
    
    
    
      
    
    
      
      
       
  

  
    
      
      
    
    
      
        
        
      
    
    
      
    
    
    
      
      
       
  

  
    
      
      
    
    
      
        
        
      
    
    
    
      
      
       
  

  
    
      
      
    
  

  
    
    
  


<PaymentReconciliation xmlns="http://hl7.org/fhir">
  <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

>

Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.