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PaymentReconciliation "ER2500" Version "1"

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A human-readable rendering of the PaymentReconciliation

{
  "resourceType" : "PaymentReconciliation",
  "id" : "ER2500",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2018-12-14T02:02:46.395Z"
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the PaymentReconciliation</div>"
  },
  "identifier" : [
    {
      "system" : "http://www.BenefitsInc.com/fhir/enrollmentresponse",
      "value" : "781234"
    }
  ],
  "status" : "active",
  "period" : {
    "start" : "2014-08-16",
    "end" : "2014-08-31"
  },
  "created" : "2014-08-16",
  "paymentIssuer" : {
    "reference" : "Organization/2"
  },
  "request" : {
    "reference" : "http://www.BenefitsInc.com/fhir/eligibility/225476332402"
  },
  "requestor" : {
    "reference" : "Organization/1"
  },
  "outcome" : "complete",
  "disposition" : "2014 August mid-month settlement.",
  "paymentDate" : "2014-08-01",
  "paymentAmount" : {
    "value" : 7000.00,
    "currency" : "USD"
  },
  "paymentIdentifier" : {
    "system" : "http://www.BenefitsInc.com/payment/2018",
    "value" : "10-12345"
  },
  "detail" : [
    {
      "identifier" : {
        "system" : "http://www.BenefitsInc.com/payment/2018/detail",
        "value" : "10-12345-001"
      },
      "type" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/payment-type",
            "code" : "payment"
          }
        ]
      },
      "request" : {
        "identifier" : {
          "system" : "http://happyvalleyclinic.com/claim",
          "value" : "AB12345"
        }
      },
      "submitter" : {
        "reference" : "Organization/1"
      },
      "response" : {
        "identifier" : {
          "system" : "http://www.BenefitsInc.com/fhir/claimresponse",
          "value" : "CR20140815-AB12345"
        }
      },
      "date" : "2014-08-16",
      "payee" : {
        "reference" : "Organization/1"
      },
      "amount" : {
        "value" : 3500.00,
        "currency" : "USD"
      }
    },
    {
      "identifier" : {
        "system" : "http://www.BenefitsInc.com/payment/2018/detail",
        "value" : "10-12345-002"
      },
      "type" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/payment-type",
            "code" : "payment"
          }
        ]
      },
      "request" : {
        "reference" : "http://www.BenefitsInc.com/fhir/oralhealthclaim/225476332699"
      },
      "date" : "2014-08-12",
      "amount" : {
        "value" : 4000.00,
        "currency" : "USD"
      }
    },
    {
      "identifier" : {
        "system" : "http://www.BenefitsInc.com/payment/2018/detail",
        "value" : "10-12345-003"
      },
      "type" : {
        "coding" : [
          {
            "system" : "http://terminology.hl7.org/CodeSystem/payment-type",
            "code" : "advance"
          }
        ]
      },
      "date" : "2014-08-16",
      "amount" : {
        "value" : -1500.00,
        "currency" : "USD"
      }
    }
  ],
  "formCode" : {
    "coding" : [
      {
        "system" : "http://ncforms.org/formid",
        "code" : "PAYREC/2016/01B"
      }
    ]
  },
  "processNote" : [
    {
      "type" : "display",
      "text" : "Due to the year end holiday the cutoff for submissions for December will be the 28th."
    }
  ]
}