<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>