<?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>