{"txn_id":"HL-UR-0871","assessment_id":"ra_5c9a3e590cec4965","occurred_at":"2026-08-27T06:36:23+00:00","state":"TX","line_of_business":"health","stage":"utilization_review","program_area":"Utilization Management/Utilization Review/Prior Authorization/Level of Care Determination","ai_system":{"system_id":"ur-auto","model_version":"2.0","vendor":"third_party","vendor_name":"ClinPath AI (fictional)","high_risk_class":"utilization_review"},"inputs":{"feature_classes":["clinical_criteria","medical_records"],"protected_factors_used":[],"ecdis_present":false,"consumer_report_used":false,"credit_used":false,"data_source_refs":["ehr://harborline/clinical-record"],"consumer_token":"tok_d8a2a79ddc"},"output":{"decision":"adverse_determination","score":0.896,"reason_codes":["MN-02"],"premium_delta_pct":null},"human_involvement":{"reviewed":true,"reviewer_role":"nurse","overridden":false},"adverse_action":{"is_adverse":true,"notice_sent_at":null,"reasons_provided":true,"specific_reasons":true,"ecdis_disclosed":false,"appeal_channel":null},"carrier_note":null,"input":{"revision":1,"current_revision":1,"input_digest":"88ede89d8ce28813509f83a096bdc12321e04074713cbcec1c326892f194706e","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":4,"general_rules_applied":0,"advisory_rules_applied":1,"rules_considered":30,"rules_applied":["doctrine.unreviewed-adverse-high-risk","tx.4201.adverse-determination-by-automated-system","tx.4201.adverse-determination-notice","tx.tdi.consequential-decision-without-human-review","tx.traiga.ai-discrimination-context"],"statement":"4 state-specific and 0 general black-letter rule(s) applied to this TX health utilization review 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","inputs.data_source_refs"],"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, inputs.data_source_refs."},"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 2026-08-27, ur-auto v2.0 (a third-party system from ClinPath AI (fictional)) produced 'adverse determination' in a TX health utilization review transaction. Inputs included clinical criteria, medical records. A human reviewed the output by a nurse. The outcome was adverse to the consumer; no notice to the consumer is recorded. RegBench applied 5 rule(s) in force on 2026-08-27 and recorded 1 finding(s); the most serious is 'Adverse utilization-review determination without a physician's determination' (critical, L2).","findings":[{"rule_id":"tx.4201.adverse-determination-by-automated-system","layer":"L2","judgment_basis":"black_letter","advisory":false,"severity":"critical","title":"Adverse utilization-review determination without a physician's determination","required_action":"Hold; route to a physician reviewer; give the provider of record the opportunity to discuss the treatment plan before any adverse determination issues.","exhibits":["C"],"content_status":"verified","citations":[{"provision_id":"tx-ins-4201-156","label":"Tex. Ins. Code § 4201.156 — use of automated decision system for adverse determinations (S.B. 815, 2025)","source_url":"https://statutes.capitol.texas.gov/?tab=1&code=IN&chapter=IN.4201","verified":true},{"provision_id":"tx-ins-4201-152","label":"Tex. Ins. Code § 4201.152 — utilization review under the direction of a physician","source_url":"https://statutes.capitol.texas.gov/?tab=1&code=IN&chapter=IN.4201","verified":true},{"provision_id":"tx-ins-4201-206","label":"Tex. Ins. Code § 4201.206 — opportunity to discuss treatment with a physician before an adverse determination","source_url":"https://statutes.capitol.texas.gov/?tab=1&code=IN&chapter=IN.4201","verified":true},{"provision_id":"tx-ins-4201-002-1c","label":"Tex. Ins. Code § 4201.002(1-c) — 'automated decision system' (utilization review)","source_url":"https://statutes.capitol.texas.gov/?tab=1&code=IN&chapter=IN.4201","verified":true}]}],"point_in_time":{"as_of":"2026-08-27","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":"2026-10-31T05:42:55.374546+00:00","fingerprint":"b469ab484302349340901456"},"review":{"status":"escalated","outcome":"escalated","hours_to_resolve":null,"reviewer_role":"physician","resolved_at":null},"ledger":{"seq":6374,"hash":"b4a584540507ca563494630f18bfafb6590adbf24358a301a27a97e4ad28bb2f","prev_hash":"2c28903b06ee077649a1a18a7960ff12aed41af73a40b0abdb22e9bc48f11f55","recorded_at":"2026-08-27T06:39:22+00:00"}}