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13.9 Resource PaymentReconciliation - Content

Financial Management icon Work GroupMaturity Level: 4 Trial UseSecurity Category: Patient Compartments: Practitioner

This resource provides the details including amount of a payment and allocates the payment items being paid.

13.9.1 Scope and Usage

The PaymentReconciliation resource provides the bulk payment details associated with a payment by the payor for receivable amounts, such as for goods and services rendered by a provider to patients covered by insurance plans offered by that payor. These are the payment reconciliation details which may align to the individual payment amounts indicated on discrete ClaimResponses or Invoices for example.

Bulk payments need to provide a means to associate the amounts paid against specific Claims, Invoices, and other financial exchanges and adjustments, to the bulk payment itself in order to reconcile accounts receivable.

The PaymentReconciliation resource is a "event" resource from a FHIR workflow perspective - see Workflow Event.

13.9.1.1 Additional Information

Additional information regarding electronic payment notice content and usage may be found at:

13.9.2 Boundaries and Relationships

The PaymentReconciliation resource serves to correlate a payment amount to the adjudicated claim amounts appearing on one or more ClaimResponses. PaymentReconciliation provides the bulk payment details associated with a payment by the payor for goods and services rendered by a provider to patients covered by insurance plans offered by that payor.

The PaymentNotice resource is used to indicate that a payment has, or is about to occur. The resource is used commonly when tracking of payment occurences is required for regulatory or business purposes.

The ClaimResponse resource is an insurer's adjudication and/or authorization of a set of healthcare-related goods and services for a patient against the patient's insurance coverages and does not indicate that payment has occured.

For reporting out to patients or transferring data to patient centered applications, such as patient health Record (PHR) application, the ExplanationOfBenefit should be used instead.

The eClaim domain includes a number of related resources

PaymentReconciliation Provides the bulk payment details associated with a payment by the payor for goods and services rendered by a provider to patients covered by insurance plans offered by that payor.
ClaimResponse A payor's adjudication and/or authorization response to the suite of services provided in a Claim. Typically the ClaimResponse references the Claim but does not duplicate the clinical or financial information provided in the claim.
ExplanationOfBenefit This resource combines the information from the Claim and the ClaimResponse, stripping out any provider or payor proprietary information, into a unified information model suitable for use for: patient reporting; transferring information to a Patient Health Record system; and, supporting complete claim and adjudication information exchange with regulatory and analytics organizations and other parts of the provider's organization.
PaymentNotice An indication that a payment has occured, is about to occur, or has been cancelled.

13.9.3 References to this Resource

13.9.4 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. PaymentReconciliation TU DomainResource PaymentReconciliation resource

Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..* Identifier Business Identifier for a payment reconciliation

... type Σ 1..1 CodeableConcept Category of payment
Binding: Payment Type Codes (Extensible)
... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: Financial Resource Status Codes (Required)
... kind 0..1 CodeableConcept Workflow originating payment
Binding: Payment Kind (Extensible)
... period Σ 0..1 Period Period covered
... created Σ 1..1 dateTime Creation date
... enterer 0..1 Reference(Practitioner | PractitionerRole | Organization) Who entered the payment
... issuerType 0..1 CodeableConcept Nature of the source
Binding: Payment Issuer Type (Extensible)
... paymentIssuer Σ 0..1 Reference(Organization | Patient | RelatedPerson) Party generating payment
... request 0..1 Reference(Task) Reference to requesting resource
... requestor 0..1 Reference(Practitioner | PractitionerRole | Organization) Responsible practitioner
... outcome 0..1 code queued | complete | error | partial
Binding: Payment Outcome (Required)
... disposition 0..1 string Disposition message
... date Σ 1..1 date When payment issued
... location 0..1 Reference(Location) Where payment collected
... method 0..1 CodeableConcept Payment instrument
Binding: hl7VS-paymentMethodCode icon (Extensible)
... cardBrand 0..1 string Type of card
... accountNumber 0..1 string Digits for verification
... expirationDate 0..1 date Expiration year-month
... processor 0..1 string Processor name
... referenceNumber 0..1 string Check number or payment reference
... authorization 0..1 string Authorization number
... tenderedAmount 0..1 Money Amount offered by the issuer
... returnedAmount 0..1 Money Amount returned by the receiver
... amount Σ 1..1 Money Total amount of Payment
... paymentIdentifier 0..1 Identifier Business identifier for the payment
... allocation 0..* BackboneElement Settlement particulars

.... identifier 0..1 Identifier Business identifier of the payment detail
.... predecessor 0..1 Identifier Business identifier of the prior payment detail
.... target 0..1 Reference(Claim | Account | Invoice | ChargeItem | Encounter | Contract) Subject of the payment
.... targetItem[x] 0..1 Sub-element of the subject
..... targetItemString string
..... targetItemIdentifier Identifier
..... targetItemPositiveInt positiveInt
.... encounter 0..1 Reference(Encounter) Applied-to encounter
.... account 0..1 Reference(Account) Applied-to account
.... type 0..1 CodeableConcept Category of payment
Binding: Payment Type Codes (Extensible)
.... submitter 0..1 Reference(Practitioner | PractitionerRole | Organization) Submitter of the request
.... response 0..1 Reference(ClaimResponse) Response committing to a payment
.... date 0..1 date Date of commitment to pay
.... responsible 0..1 Reference(PractitionerRole) Contact for the response
.... payee 0..1 Reference(Practitioner | PractitionerRole | Organization) Recipient of the payment
.... amount 0..1 Money Amount allocated to this payable
... formCode 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (Example)
... processNote 0..* BackboneElement Note concerning processing

.... type 0..1 code display | print | printoper
Binding: NoteType (Required)
.... text 0..1 string Note explanatory text

doco Documentation for this format icon

See the Extensions for this resource

 

Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis

13.9.4.1 Terminology Bindings

Path ValueSet Type Documentation
PaymentReconciliation.type PaymentTypeCodes Extensible

This value set includes sample Payment Type codes.
PaymentReconciliation.status FinancialResourceStatusCodes Required

This value set includes Status codes.
PaymentReconciliation.kind PaymentKind (a valid code from Payment Kind Codes) Extensible

The type of workflow from which this payment arose.
PaymentReconciliation.issuerType PaymentIssuerType (a valid code from Payment Issuer Type Codes) Extensible

The type of payment issuer.
PaymentReconciliation.outcome PaymentOutcome (a valid code from Claim Processing Codes) Required

The outcome of the processing.
PaymentReconciliation.method Hl7VSPaymentMethodCode icon (a valid code from paymentMethod icon) Extensible

Value Set of codes used to specify the method for the movement of payment.
PaymentReconciliation.allocation.type PaymentTypeCodes Extensible

This value set includes sample Payment Type codes.
PaymentReconciliation.formCode FormCodes Example

This value set includes a sample set of Forms codes.
PaymentReconciliation.processNote.type NoteType Required

The presentation types of notes.



13.9.5 Search Parameters

Search parameters for this resource. See also the full list of search parameters for this resource, and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
allocation-account reference The account to which payment or adjustment was applied. PaymentReconciliation.allocation.account
(Account)
allocation-encounter reference The encounter to which payment or adjustment was applied. PaymentReconciliation.allocation.encounter
(Encounter)
created date The creation date PaymentReconciliation.created
disposition string The contents of the disposition message PaymentReconciliation.disposition
identifier token The business identifier of the ExplanationOfBenefit PaymentReconciliation.identifier
outcome token The processing outcome PaymentReconciliation.outcome
payment-issuer reference The organization which generated this resource PaymentReconciliation.paymentIssuer
(Organization, Patient, RelatedPerson)
request reference The reference to the claim PaymentReconciliation.request
(Task)
requestor reference The reference to the provider who submitted the claim PaymentReconciliation.requestor
(Practitioner, Organization, PractitionerRole)
status token The status of the payment reconciliation PaymentReconciliation.status