<?xml version=“1.0” encoding=“UTF-8”?> <PaymentReconciliation xmlns=“hl7.org/fhir”>

      <id value="ER2500"/>

      <meta>
  <security>
    <system value="http://terminology.hl7.org/CodeSystem/v3-ActReason"/>
    <code value="HTEST"/>
    <display value="test health data"/>
  </security>
</meta>

      <identifier>
              <system value="http://www.BenefitsInc.com/fhir/enrollmentresponse"/>
              <value value="781234"/>
      </identifier>

      <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/Task/225476332402"/>
      </request>

      <requestor>
              <reference value="Organization/1"/>
      </requestor>

      <outcome value="complete"/>

      <disposition value="2014 August mid-month settlement."/>

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

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

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

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

              <type>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/payment-type"/>
                              <code value="payment"/>
                      </coding>
              </type>
              <request>
                      <identifier>
                              <system value="http://happyvalleyclinic.com/claim"/>
                              <value value="AB12345"/>
                      </identifier>
              </request>
              <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>   
      </detail>

      <detail>
              <identifier>
                      <system value="http://www.BenefitsInc.com/payment/2018/detail"/>
                      <value value="10-12345-002"/>
              </identifier>
              <type>
                      <coding>
                              <system value="http://terminology.hl7.org/CodeSystem/payment-type"/>
                              <code value="payment"/>
                      </coding>
              </type>
              <request>
                      <reference value="http://www.BenefitsInc.com/fhir/oralhealthclaim/225476332699"/>
              </request>
              <date value="2014-08-12"/>
              <amount>
                      <value value="4000.00"/>
                      <currency value="USD"/>
              </amount>   
      </detail>

      <detail>
              <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>   
      </detail>

      <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>