HL-UR-0985 HOLD
On 2026-09-29, 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 2026-09-29 and recorded 1 finding(s); the most serious is 'Adverse utilization-review determination without a physician's determination' (critical, L2).
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.
Evidence (carrier asserted). 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.
Findings (1)
Adverse utilization-review determination without a physician's determination
Finding. An adverse determination on a request for health care services was produced by an automated decision system and no physician determination is recorded.
Basis. § 4201.156(a): "A utilization review agent may not use an automated decision system to make, wholly or partly, an adverse determination." Utilization review must be conducted under the direction of a licensed physician (§ 4201.152), and before an adverse determination the provider must have a reasonable opportunity to discuss the treatment plan with a physician (§ 4201.206). The 2025 amendment applies to utilization review for plans delivered, issued or renewed on or after 1 January 2026.
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.
Excerpt: tx-ins-4201-156 · state statute (government edict) · in force from 2025-09-01
"(a) A utilization review agent may not use an automated decision system to make, wholly or partly, an adverse determination. (b) The commissioner may audit and inspect at any time a utilization review agent's use of an automated decision system for utilization review. (c) This section does not prohibit the use of an algorithm, artificial intelligence system, or automated decision system for administrative support or fraud-detection functions."
Excerpt: tx-ins-4201-152 · state statute (government edict) · in force from 2007-04-01
"A utilization review agent shall conduct utilization review under the direction of a physician licensed to practice medicine in this state. The physician may not hold a license to practice administrative medicine under Section 155.009, Occupations Code."
Excerpt: tx-ins-4201-206 · state statute (government edict) · in force from 2007-04-01
"(a) Subject to Subsection (b) and the notice requirements of Subchapter G, before an adverse determination is issued by a utilization review agent who questions the medical necessity, the appropriateness, or the experimental or investigational nature of a health care service, the agent shall provide the health care provider who ordered, requested, provided, or is to provide the service a reasonable opportunity to discuss with a physician licensed to practice medicine in this state the patient's treatment plan and the clinical basis for the agent's determination."
Excerpt: tx-ins-4201-002-1c · state statute (government edict) · in force from 2025-09-01
"(1-b) 'Artificial intelligence system' means any machine learning-based system that, for any explicit or implicit objective, infers from the inputs the system receives how to generate outputs, including content, decisions, predictions, and recommendations, that can influence physical or virtual environments. (1-c) 'Automated decision system' means an algorithm, including an algorithm incorporating an artificial intelligence system, that uses data-based analytics to make, suggest, or recommend certain determinations, decisions, judgments, or conclusions."
Point in time
- Law as of
- 2026-09-29
- Rules version
- 2026.10+c4982313
- Corpus snapshot
- 2026-10-30-9c5dad5a
- Engine
- regbench-engine/0.5.0 · deterministic-1
- Fingerprint
- efe2deca9e5500054aa98569 (pattern grouping, not an integrity check)
- Input digest
- 95c5ab40ec7c2994866249f6c0ec39ebc3cb7e3d949c25f3396ff02822d68281
- Evaluated
- 2026-10-31 05:42:55 UTC
- Exhibit C case file
- yes
Ledger
- Entry
- #6488 · assessment · recorded 2026-09-29T22:57:30+00:00
- Hash
- aac2c2eaafdec881bb177a45316e02983be2b8ff651caa13e0f832ec8591e76b
- Previous
- a3a4a933853b61c40123168915ff8cc4fc2681c10116751c909d7a0b4801395b
- Stored copy intact
- yes, hashes match
- Assessed input intact
- yes, revision 1 matches the input digest
Carrier review
Resolved by physician · outcome remediated · 8.1 hours after it opened · Resolved in the carrier's review queue (synthetic).
Recorded facts revision 1
As asserted by the carrier. References are recorded, not verified: RegBench holds no copy of the documents they name.
- AI system
- ur-auto v2.0 · third party (ClinPath AI (fictional)) · high-risk class: utilization review
- Governance attested
- True
- Testing report
- test://harborline/ur-auto/2026Q2
- Model documentation
- doc://harborline/ur-auto/2.0
- Feature classes
- clinical_criteria, medical_records
- Protected factors used
- none
- External data (ECDIS)
- False
- Consumer report / credit
- False / False
- Data sources
- ehr://harborline/clinical-record
- Decision
- adverse determination · score 0.761 · codes MN-02
- Human review
- yes (nurse)
- Adverse to consumer
- True
- Notice
- not recorded · reasons: True · specific: True · external data disclosed: False
- Appeal channel
- –
- Consumer token
- tok_7beecc76e1