{"txn_id":"TX-UR-0052","assessment_id":"ra_cffb6d4530d74f87","occurred_at":"2026-10-19T11:00:00+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_showcase_0052"},"output":{"decision":"adverse_determination","score":0.81,"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":"appeals@harborline.example"},"carrier_note":"Prior authorization for inpatient rehabilitation; system recommended adverse determination; nurse reviewer concurred; no physician review recorded.","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 2026-10-19, 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 2026-10-19 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"],"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":"2026-10-19","rules_version":"2026.10+dbe5ddf6","corpus_snapshot":"2026-10-30-5f07c521","engine_version":"regbench-engine/0.4.0","model_version":"deterministic-1"},"evaluated_at":"2026-10-30T11:23:25.353111+00:00","fingerprint":"c2ac66f9fd4f9b6c1406333e"},"review":{"status":"resolved","outcome":"remediated","hours_to_resolve":9.9,"reviewer_role":"physician","resolved_at":"2026-10-19T20:57:24.679252+00:00"},"ledger":{"seq":1122,"hash":"29097f6ac208aa3984413add4c07a42d98dace251106675b7f58a414d568832a","prev_hash":"6ba8250aa800db4424a800a9b346fe293e725e58e174c6be9f8d5a8dcaea7d14","recorded_at":"2026-10-19T11:03:14+00:00"}}