{"txn_id":"HL-UR-0914","assessment_id":"ra_af459c17e4874844","occurred_at":"2026-09-11T11:43:50+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_0a021ff4d3"},"output":{"decision":"adverse_determination","score":0.779,"reason_codes":["MN-02"],"premium_delta_pct":null},"human_involvement":{"reviewed":false,"reviewer_role":null,"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":"6dea12327e60366d8baa7b4eb60a57e23bcf2434a4627931f69bd44723841fa6","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: 3 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 2026-09-11, 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. No human reviewed the output before it took effect. The outcome was adverse to the consumer; no notice to the consumer is recorded. RegBench applied 5 rule(s) in force on 2026-09-11 and recorded 3 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}]},{"rule_id":"tx.tdi.consequential-decision-without-human-review","layer":"L4","judgment_basis":"guidance","advisory":false,"severity":"high","title":"Consequential AI-supported decision taken without a person reviewing and agreeing","required_action":"Route to the responsible reviewer before the outcome takes effect; record the reviewer on the transaction.","exhibits":["B","C"],"content_status":"verified","citations":[{"provision_id":"tx-tdi-b-0003-26-human-review","label":"TDI Commissioner's Bulletin B-0003-26 (12 June 2026), Use of Artificial Intelligence — human review of consequential decisions","source_url":"https://www.tdi.texas.gov/bulletins/2026/b-0003-26.html","verified":true},{"provision_id":"tx-tdi-b-0003-26-governance","label":"TDI Commissioner's Bulletin B-0003-26 (12 June 2026) — governance, procedures on request, and monitoring","source_url":"https://www.tdi.texas.gov/bulletins/2026/b-0003-26.html","verified":true}]},{"rule_id":"doctrine.unreviewed-adverse-high-risk","layer":"L6","judgment_basis":"doctrine","advisory":true,"severity":"medium","title":"Adverse outcome from a high-risk AI system with no human review","required_action":"Route to the carrier's reviewer; record the review and any override on the transaction.","exhibits":["B","C"],"content_status":"verified","citations":[{"provision_id":"naic-ai-bulletin-s3-1-ais-program","label":"NAIC Model Bulletin on the Use of AI Systems by Insurers (adopted 4 Dec 2023), Section 3, 1.0 General Guidelines — the written AIS Program","source_url":"https://content.naic.org/sites/default/files/inline-files/2023-12-4%20Model%20Bulletin_Adopted_0.pdf","verified":true}]}],"point_in_time":{"as_of":"2026-09-11","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":"2026-10-31T05:42:55.499915+00:00","fingerprint":"548497b88240674950bee063"},"review":{"status":"resolved","outcome":"remediated","hours_to_resolve":18.7,"reviewer_role":"physician","resolved_at":"2026-09-12T06:29:10.609175+00:00"},"ledger":{"seq":6417,"hash":"fdfd37fafe64b4c6164f3ee56aa08bbfbff3522d43d8fd3c0bc793815eec7db9","prev_hash":"7a7349d7aa91ddf28ba7d3ae4cb1e237c77a41e9a6ad6cd3c4276567025bdfeb","recorded_at":"2026-09-11T11:46:09+00:00"}}