<?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>