{

"resourceType": "PaymentReconciliation",
"id": "ER2500",
"text": {
  "status": "generated",
  "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the PaymentReconciliation</div>"
},
"identifier": [
  {
    "system": "http://www.BenefitsInc.com/fhir/enrollmentresponse",
    "value": "781234"
  }
],
"status": "active",
"period": {
  "start": "2014-08-16",
  "end": "2014-08-31"
},
"created": "2014-08-16",
"organization": {
  "reference": "Organization/2"
},
"request": {
  "reference": "http://www.BenefitsInc.com/fhir/ProcessRequest/225476332402"
},
"outcome": {
  "coding": [
    {
      "system": "http://hl7.org/fhir/remittance-outcome",
      "code": "complete"
    }
  ]
},
"disposition": "2014 August mid-month settlement.",
"requestProvider": {
  "reference": "Practitioner/example"
},
"requestOrganization": {
  "reference": "Organization/1"
},
"detail": [
  {
    "type": {
      "coding": [
        {
          "system": "http://hl7.org/fhir/payment-type",
          "code": "payment"
        }
      ]
    },
    "request": {
      "identifier": {
        "system": "http://happyvalleyclinic.com/claim",
        "value": "AB12345"
      }
    },
    "response": {
      "identifier": {
        "system": "http://www.BenefitsInc.com/fhir/claimresponse",
        "value": "CR20140815-AB12345"
      }
    },
    "submitter": {
      "reference": "Organization/1"
    },
    "payee": {
      "reference": "Organization/1"
    },
    "date": "2014-08-16",
    "amount": {
      "value": 1000.00,
      "system": "urn:iso:std:iso:4217",
      "code": "USD"
    }
  },
  {
    "type": {
      "coding": [
        {
          "system": "http://hl7.org/fhir/payment-type",
          "code": "payment"
        }
      ]
    },
    "request": {
      "reference": "http://www.BenefitsInc.com/fhir/oralhealthclaim/225476332699"
    },
    "date": "2014-08-12",
    "amount": {
      "value": 4000.00,
      "system": "urn:iso:std:iso:4217",
      "code": "USD"
    }
  },
  {
    "type": {
      "coding": [
        {
          "system": "http://hl7.org/fhir/payment-type",
          "code": "advance"
        }
      ]
    },
    "date": "2014-08-16",
    "amount": {
      "value": -1500.00,
      "system": "urn:iso:std:iso:4217",
      "code": "USD"
    }
  }
],
"form": {
  "coding": [
    {
      "system": "http://ncforms.org/formid",
      "code": "PAYREC/2016/01B"
    }
  ]
},
"total": {
  "value": 3500.00,
  "system": "urn:iso:std:iso:4217",
  "code": "USD"
},
"processNote": [
  {
    "type": {
      "coding": [
        {
          "system": "http://hl7.org/fhir/note-type",
          "code": "display"
        }
      ]
    },
    "text": "Due to the year end holiday the cutoff for submissions for December will be the 28th."
  }
]

}