FHIR resources for healthcare interop: implementation comparison
Denials, appeals, repair status, and pending clocks as FHIR resources shared by payers, providers, and regulators, compared with case notes that stay behind.
Why FHIR has to carry refusal and remedy
A denial and its remedy have to travel with the decision.
FHIR is how U.S. healthcare systems move data between payers, providers, and regulators. If a denial and its remedy are not in the data that moves, they are lost when the decision passes from one organization to the next.
Ethotechnics treats a denial, its appeal, and its remedy as records that travel with the decision. Each system that receives the decision can see who owns it, when an appeal must be answered, and whether the harm was repaired.
What standard AI governance implements
Process notes and case logs that do not travel with the clinical record.
- Decisioning logic captured in payer- or provider-specific case systems.
- Denials stored as narrative notes or PDF attachments.
- Appeals tracked in separate customer service workflows.
- Repair actions logged internally without interoperable status data.
- Regulators left to reconstruct timelines from siloed audit trails.
Ethotechnics implementation
FHIR as the control plane, and what to verify before launch
FHIR profiles that carry a denial, its appeal, and its remedy with the decision.
- Custom FHIR profiles for Decision, Denial, Appeal, RepairStatus, and PendingClock resources.
- A Denial resource names the clinical decision, the reason codes, and the person or body that owns the decision.
- An Appeal resource carries its status, the date it must be answered by, who it escalates to, and the evidence attached.
- An upheld Appeal points to the denial rule it overturned. A payer or a regulator can then count upheld appeals by rule and send the count to the rule's owner.
- A RepairStatus update reaches every system that received the decision, including the provider's record system and the regulator.
- A PendingClock resource shows each organization how long a decision or a repair has waited, and its deadline.
Before launch, register the profiles and confirm they validate in payer and provider systems. Map denial reasons to standardized codes. Confirm that a change in Appeal status reaches downstream systems within the stated time, and expose PendingClock resources through TEFCA-compatible exchange endpoints.
Where this fits
Health coverage and care decisions
Whether a treatment is authorized or a claim is paid, and how a patient is triaged.
- Scored cases
- No case from health care has been scored yet. One composite scenario, an appeal accepted without a remedy, is drawn from this setting.
- Standards to adopt
-
- STD-01 The Temporal Bill of Rights · Draft v1.0.3
- STD-02 Contestability and recourse · Draft v1.4.1
- STD-06 Human impact safety case · Draft v0.7.1
- Run first
- VAL-03 Latency audit. Check observed decision times against the declared deadline, such as 72 hours for an urgent request, and whether a person can be reached to escalate.
Cite this implementation example · v1.0.0 · updated Feb 1, 2025 · CC BY-SA 4.0
APA
Ethotechnics Institute. (2025). FHIR resources for healthcare interop: implementation comparison. Ethotechnics Institute. https://ethotechnics.org/use-cases/examples/fhir-resources
MLA
Ethotechnics Institute. "FHIR resources for healthcare interop: implementation comparison." Ethotechnics Institute, 2025, https://ethotechnics.org/use-cases/examples/fhir-resources.
Chicago
Ethotechnics Institute. "FHIR resources for healthcare interop: implementation comparison." Ethotechnics Institute. Feb 1, 2025. https://ethotechnics.org/use-cases/examples/fhir-resources.
BibTeX
@misc{ethotechnics_use_cases_examples_fhir_resources,
title={FHIR resources for healthcare interop: implementation comparison},
author={Ethotechnics Institute},
year={2025},
howpublished={Ethotechnics Institute},
url={https://ethotechnics.org/use-cases/examples/fhir-resources},
version={v1.0.0}
}
RIS
TY - WEB TI - FHIR resources for healthcare interop: implementation comparison AU - Ethotechnics Institute PY - 2025 UR - https://ethotechnics.org/use-cases/examples/fhir-resources ER -
See also: Standards · Mechanisms