<?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>