<?xml version=“1.0” encoding=“UTF-8”?><PaymentReconciliation xmlns=“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>

<status value="active"/>

<period>
        <start value="2014-08-16"/>
        <end value="2014-08-31"/>
</period>

<created value="2014-08-16"/>

<organization>
        <reference value="Organization/2"/>
</organization>

<request>
        <reference value="http://www.BenefitsInc.com/fhir/ProcessRequest/225476332402"/>
</request>

<outcome>
        <coding>
                <system value="http://hl7.org/fhir/remittance-outcome"/>
                <code value="complete"/>
        </coding>
</outcome>

<disposition value="2014 August mid-month settlement."/>

<requestProvider>
        <reference value="Practitioner/example"/>
</requestProvider>

<requestOrganization>
        <reference value="Organization/1"/>
</requestOrganization>

<detail>
        <type>
                <coding>
                        <system value="http://hl7.org/fhir/payment-type"/>
                        <code value="payment"/>
                </coding>
        </type>
        <request>
                <identifier>
                        <system value="http://happyvalleyclinic.com/claim"/>
                        <value value="AB12345"/>
                </identifier>
        </request>
        <response>
                <identifier>
                        <system value="http://www.BenefitsInc.com/fhir/claimresponse"/>
                        <value value="CR20140815-AB12345"/>
                </identifier>   
        </response>
        <submitter>
                <reference value="Organization/1"/>
        </submitter>
        <payee>
                <reference value="Organization/1"/>
        </payee>
        <date value="2014-08-16"/>
        <amount>
                <value value="1000.00"/>
                <system value="urn:iso:std:iso:4217"/>
                <code value="USD"/>
        </amount>   
</detail>

<detail>
        <type>
                <coding>
                        <system value="http://hl7.org/fhir/payment-type"/>
                        <code value="payment"/>
                </coding>
        </type>
        <request>
                <reference value="http://www.BenefitsInc.com/fhir/oralhealthclaim/225476332699"/>
        </request>
        <date value="2014-08-12"/>
        <amount>
                <value value="4000.00"/>
                <system value="urn:iso:std:iso:4217"/>
                <code value="USD"/>
        </amount>   
</detail>

<detail>
        <type>
                <coding>
                        <system value="http://hl7.org/fhir/payment-type"/>
                        <code value="advance"/>
                </coding>
        </type>
        <date value="2014-08-16"/>
        <amount>
                <value value="-1500.00"/>
                <system value="urn:iso:std:iso:4217"/>
                <code value="USD"/>
        </amount>   
</detail>

<form>
        <coding>
                <system value="http://ncforms.org/formid"/>
                <code value="PAYREC/2016/01B"/>
        </coding>
</form>

<total>
        <value value="3500.00"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/>
</total>  

<processNote>
        <type>
                <coding>
                        <system value="http://hl7.org/fhir/note-type"/>
                        <code value="display"/>
                </coding>
        </type>
        <text value="Due to the year end holiday the cutoff for submissions for December will be the 28th."/>
</processNote>

</PaymentReconciliation>