PAYERS & REIMBURSEMENT CONNECTORS
Adjudication, Payment Status & Reconciliation
5 of 7Integrate payer eligibility, claims, reimbursement and reconciliation workflows without turning Mediloop into a payer or payment institution.
ClaimResponseEOBAdjudicationPayment StatusReconciliationExceptionsAudit
Track Claim Outcomes
Handle accepted, rejected and partially reimbursed claims.
Monitor Payments
Track payer payment status and references.
Ensure Reconciliation
Detect expected-vs-received discrepancies.
Audit & Compliance
Maintain traceable adjudication and reconciliation history.
Adjudication & Payment Lifecycle
1
Submit Claim
Claim sent to payer
2
Payer Adjudication
Payer applies tariffs/rules
3
Receive Response
ClaimResponse/EOB and amounts
4
Payment Status
Track payer settlement reference/status
5
Reconcile
Compare expected, adjudicated and received amounts
6
Resolve Exceptions
Partial, missing, duplicate or mismatched payment
Response Data
| Field | Meaning | Source of truth |
|---|---|---|
| claimStatus | accepted / rejected / partial | Payer response |
| allowedAmount | Approved base amount | Payer response |
| reimbursedAmount | Approved reimbursement | Payer response |
| reason / EOB | Explanation codes/text | Payer response |
| paymentReference | Settlement reference | Payer/payment provider |
| paymentStatus | pending / received / reversed | Payer/payment provider |
Payment Status
Keep adjudication status distinct from payment status
Store payer settlement/reference identifiers
Track reversals/corrections explicitly
Do not equate 'claim accepted' with funds received
Use payment provider/bank records only for settlement evidence
Reconciliation
1
Expected
Claim and adjudicated amount
2
Received
Payer/payment statement
3
Match
Claim ID, payment reference, amount and date
4
Exceptions
Missing, partial, duplicate or mismatched
5
Close
Resolved with audit evidence
APIs & Examples
httpCopy
# Illustrative payment reconciliation query
GET /v1/payers/payments?from=2026-09-01&to=2026-09-30
Authorization: Bearer <token>Illustrative Mediloop app-facing route; payer/payment-provider contracts remain external and settlement is not performed by Mediloop.
Error Handling
| Exception | Resolution path |
|---|---|
| Delayed adjudication | Keep claim pending and monitor payer SLA |
| Partial reimbursement | Record item-level adjudication and expected balance |
| Missing payment reference | Manual/secondary matching queue |
| Duplicate payment | Flag and prevent double reconciliation |
| Reversal | Create explicit reversal/correction record |
Best Practices
Store full payer response and EOB
Do not mutate original adjudication evidence
Reconcile at item and payment level when payer supports it
Use exception queues with ownership/SLA
Keep payment settlement outside Mediloop financial custody
Audit reconciliation decisions and manual overrides
Developer Integration Surface
| Surface | Operation / resource | Use | Status |
|---|---|---|---|
| FHIR | ClaimResponse / ExplanationOfBenefit | Adjudication result | FHIR where supported |
| Payment status API | status / payments / remittance | Settlement tracking | Payer/provider adapter |
| Reconciliation API | match / exception / resolve | Mediloop operational reconciliation | Planned/versioned |
| Events | claim.adjudicated / payment.received / recon.exception | Async operations | Planned/evolving |
Next Steps
Map payer response codes
Implement adjudication state machine
Connect settlement-status source
Build automated reconciliation
Add exception review and audit