Path | Short | Definition | Comments |
---|---|---|---|
PaymentReconciliation resource | This resource provides the details including amount of a payment and allocates the payment items being paid. | ||
identifier | Business Identifier for a payment reconciliation | A unique identifier assigned to this payment reconciliation. | |
status | active | cancelled | draft | entered-in-error | The status of the resource instance. | This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. |
period | Period covered | The period of time for which payments have been gathered into this bulk payment for settlement. | |
created | Creation date | The date when the resource was created. | |
paymentIssuer | Party generating payment | The party who generated the payment. | This party is also responsible for the reconciliation. |
request | Reference to requesting resource | Original request resource reference. | |
requestor | Responsible practitioner | The practitioner who is responsible for the services rendered to the patient. | |
outcome | queued | complete | error | partial | The outcome of a request for a reconciliation. | The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete). |
disposition | Disposition message | A human readable description of the status of the request for the reconciliation. | |
paymentDate | When payment issued | The date of payment as indicated on the financial instrument. | |
paymentAmount | Total amount of Payment | Total payment amount as indicated on the financial instrument. | |
paymentIdentifier | Business identifier for the payment | Issuer's unique identifier for the payment instrument. | For example: EFT number or check number. |
detail | Settlement particulars | Distribution of the payment amount for a previously acknowledged payable. | |
detail.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
detail.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
detail.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
detail.identifier | Business identifier of the payment detail | Unique identifier for the current payment item for the referenced payable. | |
detail.predecessor | Business identifier of the prior payment detail | Unique identifier for the prior payment item for the referenced payable. | |
detail.type | Category of payment | Code to indicate the nature of the payment. | For example: payment, adjustment, funds advance, etc. |
detail.request | Request giving rise to the payment | A resource, such as a Claim, the evaluation of which could lead to payment. | |
detail.submitter | Submitter of the request | The party which submitted the claim or financial transaction. | |
detail.response | Response committing to a payment | A resource, such as a ClaimResponse, which contains a commitment to payment. | |
detail.date | Date of commitment to pay | The date from the response resource containing a commitment to pay. | |
detail.responsible | Contact for the response | A reference to the individual who is responsible for inquiries regarding the response and its payment. | |
detail.payee | Recipient of the payment | The party which is receiving the payment. | |
detail.amount | Amount allocated to this payable | The monetary amount allocated from the total payment to the payable. | |
formCode | Printed form identifier | A code for the form to be used for printing the content. | May be needed to identify specific jurisdictional forms. |
processNote | Note concerning processing | A note that describes or explains the processing in a human readable form. | |
processNote.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
processNote.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
processNote.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
processNote.type | display | print | printoper | The business purpose of the note text. | |
processNote.text | Note explanatory text | The explanation or description associated with the processing. |
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.
Additional information regarding electronic payment notice content and usage may be found at:
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. |
created | The creation date | PaymentReconciliation.created |
disposition | The contents of the disposition message | PaymentReconciliation.disposition |
identifier | The business identifier of the ExplanationOfBenefit | PaymentReconciliation.identifier |
outcome | The processing outcome | PaymentReconciliation.outcome |
payment-issuer | The organization which generated this resource | PaymentReconciliation.paymentIssuer |
request | The reference to the claim | PaymentReconciliation.request |
requestor | The reference to the provider who submitted the claim | PaymentReconciliation.requestor |
status | The status of the payment reconciliation | PaymentReconciliation.status |