{"txn_id":"HL-CLM-1055","assessment_id":"ra_7671aa6750bd4eee","occurred_at":"2026-10-07T19:54:33+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_1456775d4e"},"output":{"decision":"partial_pay","score":0.594,"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,"assessment":{"disposition":"HOLD","summary":"HOLD: 1 finding(s) under rules 2026.10+dbe5ddf6, corpus 2026-10-30-5f07c521. Held for the carrier's compliance review before the outcome is communicated; the carrier decides.","narrative":"On 2026-10-07, 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 2026-10-07 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"],"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":"2026-10-07","rules_version":"2026.10+dbe5ddf6","corpus_snapshot":"2026-10-30-5f07c521","engine_version":"regbench-engine/0.4.0","model_version":"deterministic-1"},"evaluated_at":"2026-10-30T11:23:25.209540+00:00","fingerprint":"d8155888ad219bd74dce9105"},"review":{"status":"open","outcome":null,"hours_to_resolve":null,"reviewer_role":null,"resolved_at":null},"ledger":{"seq":1055,"hash":"805c128a02f6db9b8ec35fe0b9ed417e8b3561f3b409ad2fc5e76c9de7bfbed8","prev_hash":"1fc7b3e35e2fbcdc82e34855d771f9391a7b2c15f2c83e925da06cd0ef099133","recorded_at":"2026-10-07T19:56:32+00:00"}}