{"txn_id":"HL-CLM-1011","assessment_id":"ra_d432e03de4d44216","occurred_at":"2026-09-08T20:48:38+00:00","state":"TX","line_of_business":"health","stage":"claims","program_area":"Claims/Adjudication","ai_system":{"system_id":"claims-adjud","model_version":"5.1","vendor":"internal","vendor_name":null,"high_risk_class":"claims"},"inputs":{"feature_classes":["medical_records","claims_history"],"protected_factors_used":[],"ecdis_present":false,"consumer_report_used":false,"credit_used":false,"data_source_refs":[],"consumer_token":"tok_fc1e962a0f"},"output":{"decision":"partial_pay","score":0.552,"reason_codes":[],"premium_delta_pct":null},"human_involvement":{"reviewed":true,"reviewer_role":"adjuster","overridden":false},"adverse_action":{"is_adverse":true,"notice_sent_at":null,"reasons_provided":false,"specific_reasons":false,"ecdis_disclosed":false,"appeal_channel":null},"carrier_note":null,"input":{"revision":1,"current_revision":1,"input_digest":"4785dd310f60c636944377f4d8dc6ab9b73a58cca7b3343919be9f0b566d68a8","digest_ok":true,"note":"input_digest is SHA-256 over the canonical JSON of the transaction revision assessed; it is inside the assessment the ledger hashes."},"assessment":{"disposition":"HOLD","coverage":{"status":"supported","state_rules_applied":6,"general_rules_applied":0,"advisory_rules_applied":1,"rules_considered":30,"rules_applied":["doctrine.unreviewed-adverse-high-risk","tx.544.prohibited-basis","tx.542.rejection-without-reasons","tx.542.algorithmic-denial-without-human-review","tx.tdi.consequential-decision-without-human-review","tx.tdi.third-party-data-source-unrecorded","tx.traiga.ai-discrimination-context"],"statement":"6 state-specific and 0 general black-letter rule(s) applied to this TX health claims transaction. Only the configured checks were run; a result is not a legal opinion on compliance."},"evidence":{"status":"carrier_asserted","asserted":["ai_system.governance_attested","ai_system.model_doc_ref","ai_system.testing_report_ref"],"missing":[],"statement":"Supplied by the carrier and not verified by RegBench: ai_system.governance_attested, ai_system.model_doc_ref, ai_system.testing_report_ref."},"summary":"HOLD: 1 finding(s) under rules 2026.10+c4982313, corpus 2026-10-30-9c5dad5a. Recommended hold for the carrier's compliance review before the outcome is communicated; the carrier decides.","narrative":"On 2026-09-08, claims-adjud v5.1 (an internally developed system) produced 'partial pay' in a TX health claims transaction. Inputs included medical records, claims history. A human reviewed the output by a adjuster. The outcome was adverse to the consumer; no notice to the consumer is recorded. RegBench applied 7 rule(s) in force on 2026-09-08 and recorded 1 finding(s); the most serious is 'Claim rejected or reduced without stated reasons' (high, L2).","findings":[{"rule_id":"tx.542.rejection-without-reasons","layer":"L2","judgment_basis":"black_letter","advisory":false,"severity":"high","title":"Claim rejected or reduced without stated reasons","required_action":"Hold the rejection until the reasons are stated in the claimant notice and recorded; confirm the 15-business-day clock.","exhibits":["C"],"content_status":"verified","citations":[{"provision_id":"tx-ins-542-056","label":"Tex. Ins. Code § 542.056 — notice of acceptance or rejection of claim; reasons for rejection","source_url":"https://statutes.capitol.texas.gov/?tab=1&code=IN&chapter=IN.542","verified":true},{"provision_id":"tx-ins-542-003","label":"Tex. Ins. Code § 542.003 — unfair claim settlement practices prohibited","source_url":"https://statutes.capitol.texas.gov/?tab=1&code=IN&chapter=IN.542","verified":true}]}],"point_in_time":{"as_of":"2026-09-08","basis":"transaction_date","rules_version":"2026.10+c4982313","corpus_snapshot":"2026-10-30-9c5dad5a","engine_version":"regbench-engine/0.5.0","model_version":"deterministic-1"},"evaluated_at":"2026-10-31T05:42:55.760806+00:00","fingerprint":"bf6f8acff048caacb18ea7bc"},"review":{"status":"resolved","outcome":"overridden","hours_to_resolve":5.8,"reviewer_role":"adjuster","resolved_at":"2026-09-09T02:40:46.510244+00:00"},"ledger":{"seq":6514,"hash":"73e320027ad0563a3d2ae3b9e0786a1b4fa2e3e1b0c980930104810a692c3885","prev_hash":"c5865577267920b26d65947fba77dd0235cbe020fb4635ae678a0e24295ab900","recorded_at":"2026-09-08T20:51:39+00:00"}}