{

"resourceType": "PaymentReconciliation",
"id": "ER2500",
"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/Task/225476332402"
},
"requestor": {
  "reference": "Organization/1"
},
"outcome": "complete",
"disposition": "2014 August mid-month settlement.",
"paymentDate": "2014-08-01",
"paymentAmount": {
  "value": 7000.0,
  "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": 3500.0,
      "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": 4000.0,
      "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": -1500.0,
      "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."
  }
],
"meta": {
  "tag": [
    {
      "system": "http://terminology.hl7.org/CodeSystem/v3-ActReason",
      "code": "HTEST",
      "display": "test health data"
    }
  ]
}

}