{"txn_id":"TX-UR-0052","assessment_id":"ra_1239ccef455e4647","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.","input":{"revision":1,"current_revision":1,"input_digest":"70aa4f969b186bc0c6790b3391eff58ec939a879c78a9b9fcf1198aef177076a","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 2026-10-19, 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"],"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":"2026-10-19","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":"2026-10-31T05:42:56.114145+00:00","fingerprint":"4f73f0e18b07be3bcd315de0"},"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":6625,"hash":"97f82c15781c0437ee8f11fb018f37124f519e71f0a035c53f847685f3899952","prev_hash":"02a7695706df850c9021fbea213754b9e7ce3d756f8bd8b046e37695ae418456","recorded_at":"2026-10-19T11:03:14+00:00"}}