{ "file_id": "03_vertical_insurance_pc_life_annuity", "version": "2026.03.16", "schema_version": "2.2", "status": "Production Authority", "last_authoritative_sync": "2026-03-16", "description": "Comprehensive enumeration library for the Insurance vertical — Property & Casualty, Life & Annuity, Health, and Specialty/Reinsurance. Covers every subdomain where agentic AI is actively deployed as of March 2026: policy lifecycle, underwriting, rating and pricing, claims intake and adjudication, fraud detection, subrogation, loss mitigation, reinsurance, and regulatory reporting. Designed for use as OTel span attributes in an agentic AI SDK and as policy vocabulary in an OPA Rego GRC portal.", "vertical_metadata": { "vertical_key": "insurance", "industry": "Insurance: P&C, Life & Annuity", "primary_standards": [ "ACORD 2.0 — P&C XML and AL3 Standards", "ACORD Life & Annuity XML (OLI/TXLife)", "ACORD GRLC Generation 2.0 — Global Reinsurance & Large Commercial (April 2025)", "ACORD Next-Generation Digital Standards — JSON-based microservices API standard", "NAIC Model Bulletin: Use of Artificial Intelligence Systems by Insurers (December 2023; 24 states adopted as of March 2025)", "NAIC Model Act #880 — Unfair Trade Practices Act", "NAIC Model Act #900 — Unfair Claims Settlement Practices Act", "Colorado SB21-169 / Regulation 10-1-1 — Governance and Risk Management for ECDIS use (effective Oct 15, 2025; expanded to auto and health)", "New York DFS Insurance Circular Letter No. 7 (July 2024) — AI transparency expectations", "California Insurance Code §10123.135 — Prohibition on solely automated health care decisions", "HL7 FHIR v6.0 — ClaimResponse and ExplanationOfBenefit resources (health insurance claims)", "CMS Interoperability and Prior Authorization Final Rule (2024) — 72-hour expedited / 7-day standard PA timelines", "NAIC Own Risk and Solvency Assessment (ORSA) Model Act #505", "Lloyd's Blueprint Two Core Data Record (CDR) — built on ACORD standards", "EU Solvency II Directive — Pillar 2 model governance and internal model validation" ], "primary_source_urls": [ "https://www.acord.org/standards-architecture/acord-data-standards", "https://acord.org/ACORD-about/acord-news/2025/04/10/acord-launches-grlc-generation-2.0-data-standards", "https://content.naic.org/sites/default/files/inline-files/2023-12-4%20Model%20Bulletin_Adopted_0.pdf", "https://doi.colorado.gov/for-consumers/sb21-169-protecting-consumers-from-unfair-discrimination-in-insurance-practices", "https://www.dfs.ny.gov/industry_guidance/circular_letters/cl2024_07", "https://build.fhir.org/claimresponse.html" ], "otel_namespace": "insurance", "opa_namespace": "data.insurance", "agentic_ai_deployment_context": "As of March 2026, agentic AI in insurance is deployed across: first notice of loss (FNOL) intake and triage, automated claims severity assessment, straight-through claims processing (STP) for low-complexity claims, AI-assisted underwriting decisioning, telematics-driven auto rating, predictive model governance and bias testing (NAIC Model Bulletin, Colorado Reg 10-1-1), prior authorisation adjudication (health), fraud ring detection, subrogation opportunity identification, reinsurance placement data preparation (ACORD GRLC Gen 2.0), and ORSA narrative generation. The NAIC Model Bulletin now operates as de facto national standard, enforced via state market conduct examinations.", "key_regulatory_risk_note": "92% of health insurers, 88% of auto insurers, and 70% of home insurers report current or planned AI use (NAIC 2025 survey). The NAIC Model Bulletin requires insurers to maintain an AIS (AI System) Program covering governance, consumer notice, risk management, internal controls, and vendor management for every AI system that makes or supports regulated insurance decisions. Colorado Regulation 10-1-1 extends mandatory bias testing and annual compliance reporting to life, auto, and health lines (effective Oct 15, 2025). The UnitedHealth/NaviHealth nH Predict and Cigna PxDx class-action cases demonstrate that autonomous AI claims denial without physician review creates direct litigation exposure." }, "subdomains": [ { "subdomain": "Policy Lifecycle & Administration", "description": "Covers the full policy lifecycle from quote through cancellation and reinstatement. Agentic AI manages quote generation, policy issuance, endorsement processing, renewals, and policy document generation. ACORD OLI_LU_POLSTAT type codes govern P&C and L&A status values.", "acord_references": [ "OLI_LU_POLSTAT", "ACORD 2.0 P&C XML", "OLI/TXLife" ], "categories": [ { "enum_name": "PolicyLifecycleStatus", "label": "Policy Lifecycle Status", "otel_attribute": "insurance.policy.lifecycle_status", "opa_policy_path": "data.insurance.policy.lifecycle_status", "rego_input_key": "insurance_policy_lifecycle_status", "stability": "stable", "description": "The current lifecycle status of an insurance policy. Semantic labels align to ACORD OLI_LU_POLSTAT codes, which are captured in code_definitions for interoperability reference.", "permitted_values": [ "application_received", "quoted", "bound", "issued", "in_force", "lapsed", "cancelled_flat", "cancelled_pro_rata", "expired", "reinstated", "matured", "surrendered", "reduced_paid_up", "extended_term", "claim_in_progress", "terminated", "non_renewed", "rescinded" ], "value_labels": { "application_received": "Application Received", "quoted": "Quoted", "bound": "Bound", "issued": "Issued", "in_force": "In Force", "lapsed": "Lapsed", "cancelled_flat": "Cancelled Flat", "cancelled_pro_rata": "Cancelled Pro Rata", "expired": "Expired", "reinstated": "Reinstated", "matured": "Matured", "surrendered": "Surrendered", "reduced_paid_up": "Reduced Paid Up", "extended_term": "Extended Term", "claim_in_progress": "Claim in Progress", "terminated": "Terminated", "non_renewed": "Non Renewed", "rescinded": "Rescinded" }, "source": "ACORD OLI_LU_POLSTAT Type Codes; ACORD 2.0 P&C and L&A standards", "source_url": "https://modelviewers.pilotfishtechnology.com/modelviewers/ACORD/model/typecodes/OLI_LU_POLSTAT.html", "code_definitions": { "application_received": "OLI_POLSTAT_APPLIED", "quoted": "OLI_POLSTAT_QUOTED", "bound": "OLI_POLSTAT_BOUND", "issued": "OLI_POLSTAT_ISSUED", "in_force": "OLI_POLSTAT_INFORCE", "lapsed": "OLI_POLSTAT_LAPSED", "cancelled_flat": "OLI_POLSTAT_CANCELLED", "expired": "OLI_POLSTAT_EXPIRED", "matured": "OLI_POLSTAT_MATURED", "surrendered": "OLI_POLSTAT_SURRENDERED", "terminated": "OLI_POLSTAT_TERMINATED", "reinstated": "OLI_POLSTAT_REINSTATED" } }, { "enum_name": "PolicyTransactionType", "label": "Policy Transaction Type", "otel_attribute": "insurance.policy.transaction_type", "opa_policy_path": "data.insurance.policy.transaction_type", "rego_input_key": "insurance_policy_transaction_type", "stability": "stable", "description": "Type of transaction being processed on a policy. Agentic policy administration agents must tag every action with this enum to enable audit trail generation and state filing compliance.", "permitted_values": [ "new_business", "renewal", "endorsement_add_coverage", "endorsement_remove_coverage", "endorsement_change_coverage", "endorsement_add_insured", "endorsement_remove_insured", "endorsement_address_change", "endorsement_vehicle_change", "reinstatement", "cancellation_voluntary", "cancellation_non_payment", "cancellation_underwriting", "non_renewal_insurer_initiated", "non_renewal_policyholder_initiated", "rewrite", "conversion", "reinsurance_cession", "audit_premium_adjustment" ], "value_labels": { "new_business": "New Business", "renewal": "Renewal", "endorsement_add_coverage": "Endorsement Add Coverage", "endorsement_remove_coverage": "Endorsement Remove Coverage", "endorsement_change_coverage": "Endorsement Change Coverage", "endorsement_add_insured": "Endorsement Add Insured", "endorsement_remove_insured": "Endorsement Remove Insured", "endorsement_address_change": "Endorsement Address Change", "endorsement_vehicle_change": "Endorsement Vehicle Change", "reinstatement": "Reinstatement", "cancellation_voluntary": "Cancellation Voluntary", "cancellation_non_payment": "Cancellation Non Payment", "cancellation_underwriting": "Cancellation Underwriting", "non_renewal_insurer_initiated": "Non Renewal Insurer Initiated", "non_renewal_policyholder_initiated": "Non Renewal Policyholder Initiated", "rewrite": "Rewrite", "conversion": "Conversion", "reinsurance_cession": "Reinsurance Cession", "audit_premium_adjustment": "Audit Premium Adjustment" }, "source": "ACORD 2.0 P&C XML Transaction Types; ACORD Life TXLife transaction types" }, { "enum_name": "InsuranceLineOfBusiness", "label": "Insurance Line of Business", "otel_attribute": "insurance.policy.line_of_business", "opa_policy_path": "data.insurance.policy.line_of_business", "rego_input_key": "insurance_policy_line_of_business", "stability": "stable", "description": "The insurance line of business. Drives regulatory jurisdiction, form filing requirements, and applicable NAIC model acts. Also determines which state AI regulations apply (Colorado Reg 10-1-1 applies to life, auto, and health).", "permitted_values": [ "personal_auto", "homeowners", "renters", "personal_umbrella", "commercial_auto", "commercial_general_liability", "commercial_property", "businessowners_bop", "workers_compensation", "professional_liability_eo", "directors_officers_do", "cyber_liability", "commercial_umbrella_excess", "marine_inland", "marine_ocean", "aviation", "surety_bond", "crop_agriculture", "flood_nfip", "title_insurance", "term_life", "whole_life", "universal_life", "variable_life", "indexed_universal_life", "annuity_fixed", "annuity_variable", "annuity_fixed_indexed", "long_term_care", "disability_income", "health_individual", "health_group", "medicare_advantage", "medicaid_managed_care", "dental_vision", "specialty_reinsurance", "treaty_reinsurance", "facultative_reinsurance" ], "value_labels": { "personal_auto": "Personal Auto", "homeowners": "Homeowners", "renters": "Renters", "personal_umbrella": "Personal Umbrella", "commercial_auto": "Commercial Auto", "commercial_general_liability": "Commercial General Liability", "commercial_property": "Commercial Property", "businessowners_bop": "Businessowners Bop", "workers_compensation": "Workers Compensation", "professional_liability_eo": "Professional Liability Eo", "directors_officers_do": "Directors Officers Do", "cyber_liability": "Cyber Liability", "commercial_umbrella_excess": "Commercial Umbrella Excess", "marine_inland": "Marine Inland", "marine_ocean": "Marine Ocean", "aviation": "Aviation", "surety_bond": "Surety Bond", "crop_agriculture": "Crop Agriculture", "flood_nfip": "Flood Nfip", "title_insurance": "Title Insurance", "term_life": "Term Life", "whole_life": "Whole Life", "universal_life": "Universal Life", "variable_life": "Variable Life", "indexed_universal_life": "Indexed Universal Life", "annuity_fixed": "Annuity Fixed", "annuity_variable": "Annuity Variable", "annuity_fixed_indexed": "Annuity Fixed Indexed", "long_term_care": "Long Term Care", "disability_income": "Disability Income", "health_individual": "Health Individual", "health_group": "Health Group", "medicare_advantage": "Medicare Advantage", "medicaid_managed_care": "Medicaid Managed Care", "dental_vision": "Dental Vision", "specialty_reinsurance": "Specialty Reinsurance", "treaty_reinsurance": "Treaty Reinsurance", "facultative_reinsurance": "Facultative Reinsurance" }, "regulatory_mappings": { "colorado_reg_10_1_1": "Effective Oct 15, 2025: applies to life, personal_auto, health_individual, health_group, medicare_advantage", "naic_model_bulletin": "Applies across all lines where AI makes or supports regulated insurance decisions", "nfip": "Flood coverage under National Flood Insurance Program — federally underwritten" }, "source": "NAIC Annual Statement lines of business; ACORD line of business taxonomy; Colorado Division of Insurance" }, { "enum_name": "PolicyCancellationReasonCode", "label": "Policy Cancellation Reason Code", "otel_attribute": "insurance.policy.cancellation_reason", "opa_policy_path": "data.insurance.policy.cancellation_reason", "rego_input_key": "insurance_policy_cancellation_reason", "stability": "stable", "description": "Standardised reason codes for policy cancellation. State insurance regulations mandate specific notice periods and permissible reasons that vary by line of business. Agentic cancellation agents must validate reason code against state-specific requirements before initiating.", "permitted_values": [ "non_payment_of_premium", "material_misrepresentation", "fraud", "change_in_risk_unacceptable", "moral_hazard", "loss_of_reinsurance", "regulatory_requirement", "underwriting_guideline_change", "policyholder_requested", "duplicate_policy", "insured_deceased", "business_closed", "property_sold", "vehicle_sold", "moving_out_of_state", "coverage_no_longer_needed" ], "value_labels": { "non_payment_of_premium": "Non Payment of Premium", "material_misrepresentation": "Material Misrepresentation", "fraud": "Fraud", "change_in_risk_unacceptable": "Change in Risk Unacceptable", "moral_hazard": "Moral Hazard", "loss_of_reinsurance": "Loss of Reinsurance", "regulatory_requirement": "Regulatory Requirement", "underwriting_guideline_change": "Underwriting Guideline Change", "policyholder_requested": "Policyholder Requested", "duplicate_policy": "Duplicate Policy", "insured_deceased": "Insured Deceased", "business_closed": "Business Closed", "property_sold": "Property Sold", "vehicle_sold": "Vehicle Sold", "moving_out_of_state": "Moving Out of State", "coverage_no_longer_needed": "Coverage No Longer Needed" }, "regulatory_mappings": { "naic_personal_lines_cancellation": "NAIC Model Act #38-1 — Personal Lines Property and Casualty Insurance Cancellation and Nonrenewal Model Act", "state_cancellation_laws": "State-specific minimum notice periods: typically 10 days for non-payment, 30 days for other reasons" }, "source": "NAIC Model Act #38-1; state insurance cancellation statutes; ACORD cancellation transaction types" } ] }, { "subdomain": "Underwriting, Rating & Pricing", "description": "Covers automated underwriting, AI-assisted risk scoring, and rate/pricing decisions. This is the highest-risk subdomain for regulatory scrutiny — the NAIC Model Bulletin, Colorado Reg 10-1-1, and NY DFS Circular Letter 7 all directly target AI use in underwriting and rating. All AI underwriting decisions must be explainable and auditable for bias.", "categories": [ { "enum_name": "UnderwritingDecisionStatus", "label": "Underwriting Decision Status", "otel_attribute": "insurance.underwriting.decision_status", "opa_policy_path": "data.insurance.underwriting.decision_status", "rego_input_key": "insurance_underwriting_decision_status", "stability": "stable", "description": "Defines the allowed values for Underwriting Decision Status in the Insurance: P&C, Life & Annuity catalog so OpenTelemetry spans and OPA policy inputs remain consistent across VeriProof. Terminology aligns to ACORD Underwriting Logic; NAIC Model Bulletin (Dec 2023).", "permitted_values": [ "accepted_standard", "accepted_preferred", "accepted_rated", "accepted_with_exclusions", "accepted_restricted_coverage", "conditional_pending_inspection", "conditional_pending_medical_records", "conditional_pending_financial_records", "referred_to_senior_underwriter", "referred_to_reinsurer", "declined_unacceptable_risk", "declined_outside_appetite", "declined_regulatory_prohibition", "postponed_temporary", "cancelled_post_bind" ], "value_labels": { "accepted_standard": "Accepted Standard", "accepted_preferred": "Accepted Preferred", "accepted_rated": "Accepted Rated", "accepted_with_exclusions": "Accepted with Exclusions", "accepted_restricted_coverage": "Accepted Restricted Coverage", "conditional_pending_inspection": "Conditional Pending Inspection", "conditional_pending_medical_records": "Conditional Pending Medical Records", "conditional_pending_financial_records": "Conditional Pending Financial Records", "referred_to_senior_underwriter": "Referred to Senior Underwriter", "referred_to_reinsurer": "Referred to Reinsurer", "declined_unacceptable_risk": "Declined Unacceptable Risk", "declined_outside_appetite": "Declined Outside Appetite", "declined_regulatory_prohibition": "Declined Regulatory Prohibition", "postponed_temporary": "Postponed Temporary", "cancelled_post_bind": "Cancelled Post Bind" }, "regulatory_mappings": { "naic_model_bulletin": "All AI-supported underwriting decisions subject to AIS Program governance and consumer notice requirements", "naic_utp_act_880": "NAIC #880 — Unfair Trade Practices Act: AI-driven underwriting cannot constitute unfair discrimination", "colorado_reg_10_1_1": "Annual bias testing and compliance reporting for life, auto, and health underwriting AI (effective Oct 15, 2025)" }, "source": "ACORD Underwriting Logic; NAIC Model Bulletin (Dec 2023)" }, { "enum_name": "UnderwritingAIModelType", "label": "Underwriting AI Model Type", "otel_attribute": "insurance.underwriting.ai_model_type", "opa_policy_path": "data.insurance.underwriting.ai_model_type", "rego_input_key": "insurance_underwriting_ai_model_type", "stability": "proposed", "description": "The type of AI or predictive model used in an underwriting or rating decision. Must be declared in the AIS Program and subject to governance documentation per the NAIC Model Bulletin.", "permitted_values": [ "traditional_rule_based_engine", "credit_based_insurance_score", "telematics_driving_score", "predictive_loss_model", "external_consumer_data_ecdis_model", "third_party_vendor_model", "generative_ai_narrative", "computer_vision_property_inspection", "natural_language_processing_document", "graph_neural_network_fraud", "ensemble_hybrid_model", "large_language_model_llm" ], "value_labels": { "traditional_rule_based_engine": "Traditional Rule Based Engine", "credit_based_insurance_score": "Credit Based Insurance Score", "telematics_driving_score": "Telematics Driving Score", "predictive_loss_model": "Predictive Loss Model", "external_consumer_data_ecdis_model": "External Consumer Data (ECDIS) Model", "third_party_vendor_model": "Third Party Vendor Model", "generative_ai_narrative": "Generative AI Narrative", "computer_vision_property_inspection": "Computer Vision Property Inspection", "natural_language_processing_document": "Natural Language Processing Document", "graph_neural_network_fraud": "Graph Neural Network Fraud", "ensemble_hybrid_model": "Ensemble Hybrid Model", "large_language_model_llm": "Large Language Model (LLM)" }, "regulatory_mappings": { "naic_model_bulletin": "All model types require documentation in AIS Program; third-party vendor models require vendor management oversight", "colorado_sb21_169": "All model types using ECDIS require bias testing and governance framework", "ny_dfs_cl7_2024": "New York DFS expects transparency and explainability documentation for all AI model types" }, "source": "NAIC Model Bulletin Section 3 — governance and risk management for AI systems; Colorado Regulation 10-1-1" }, { "enum_name": "RatingFactorCategory", "label": "Rating Factor Category", "otel_attribute": "insurance.rating.factor_category", "opa_policy_path": "data.insurance.rating.factor_category", "rego_input_key": "insurance_rating_factor_category", "stability": "proposed", "description": "Categories of rating factors used by agentic pricing agents. Classifying each factor enables OPA rules to block use of prohibited proxy factors and enforce state filing requirements.", "permitted_values": [ "traditional_actuarial_factor", "credit_based_insurance_score", "telematics_driving_behavior", "iot_sensor_home_monitoring", "geospatial_hazard_data", "aerial_imagery_property", "motor_vehicle_record_mvr", "claims_history_internal", "claims_history_clue", "social_determinants_of_health", "external_consumer_data_ecdis", "social_media_derived", "purchase_behavior_derived", "genomic_genetic_data", "prohibited_characteristic_proxy" ], "value_labels": { "traditional_actuarial_factor": "Traditional Actuarial Factor", "credit_based_insurance_score": "Credit Based Insurance Score", "telematics_driving_behavior": "Telematics Driving Behavior", "iot_sensor_home_monitoring": "IoT Sensor Home Monitoring", "geospatial_hazard_data": "Geospatial Hazard Data", "aerial_imagery_property": "Aerial Imagery Property", "motor_vehicle_record_mvr": "Motor Vehicle Record (MVR)", "claims_history_internal": "Claims History Internal", "claims_history_clue": "Claims History (CLUE)", "social_determinants_of_health": "Social Determinants of Health", "external_consumer_data_ecdis": "External Consumer Data (ECDIS)", "social_media_derived": "Social Media Derived", "purchase_behavior_derived": "Purchase Behavior Derived", "genomic_genetic_data": "Genomic Genetic Data", "prohibited_characteristic_proxy": "Prohibited Characteristic Proxy" }, "regulatory_mappings": { "colorado_sb21_169": "ECDIS factors require bias testing for proxy discrimination", "naic_model_bulletin": "External consumer data factors must be disclosed in AIS Program", "state_rate_filing": "Rate factors must be filed with and approved by state insurance departments", "hipaa_gina": "Genomic and genetic data prohibited in most life and health underwriting contexts" }, "use_case": "OPA rule: deny any rating action where factor_category is prohibited_characteristic_proxy or social_media_derived until Colorado Reg 10-1-1 bias test has been completed and approved.", "source": "Colorado SB21-169 ECDIS definition; NAIC Big Data Working Group reports; state rate filing requirements" }, { "enum_name": "ECDISBiasTestOutcome", "label": "ECDIS Bias Test Outcome", "otel_attribute": "insurance.underwriting.ecdis_bias_test_outcome", "opa_policy_path": "data.insurance.underwriting.ecdis_bias_test_outcome", "rego_input_key": "insurance_underwriting_ecdis_bias_test_outcome", "stability": "proposed", "description": "Outcome of the required bias and disparate impact testing for AI models using External Consumer Data and Information Sources (ECDIS). Required by Colorado Regulation 10-1-1 and NAIC Model Bulletin for life, auto, and health lines.", "permitted_values": [ "testing_not_required_no_ecdis_used", "testing_not_yet_performed", "testing_in_progress", "no_disparate_impact_detected", "minor_disparity_within_tolerance", "material_disparity_corrective_action_pending", "material_disparity_corrective_action_complete", "model_suspended_pending_remediation", "test_failed_methodology_issue", "filed_with_division_of_insurance", "approved_by_division_of_insurance" ], "value_labels": { "testing_not_required_no_ecdis_used": "Testing Not Required - No ECDIS Used", "testing_not_yet_performed": "Testing not Yet Performed", "testing_in_progress": "Testing in Progress", "no_disparate_impact_detected": "No Disparate Impact Detected", "minor_disparity_within_tolerance": "Minor Disparity Within Tolerance", "material_disparity_corrective_action_pending": "Material Disparity Corrective Action Pending", "material_disparity_corrective_action_complete": "Material Disparity Corrective Action Complete", "model_suspended_pending_remediation": "Model Suspended Pending Remediation", "test_failed_methodology_issue": "Test Failed Methodology Issue", "filed_with_division_of_insurance": "Filed with Division of Insurance", "approved_by_division_of_insurance": "Approved by Division of Insurance" }, "regulatory_mappings": { "colorado_reg_10_1_1": "Annual compliance report due Dec 1 (life); July 1, 2026 (auto and health); bias test outcomes must be documented", "naic_model_bulletin": "Risk management controls must address potential disparate impact in AI system outputs" }, "use_case": "OPA rule: block production deployment of any underwriting model where ecdis_bias_test_outcome is testing_not_yet_performed, material_disparity_corrective_action_pending, or model_suspended_pending_remediation.", "source": "Colorado Division of Insurance SB21-169 Regulation 10-1-1 (effective Oct 15, 2025); NAIC Model Bulletin" }, { "enum_name": "InsuranceAIModelInventoryStatus", "label": "Insurance AI Model Inventory Status", "otel_attribute": "insurance.ai_model.inventory_status", "opa_policy_path": "data.insurance.ai_model.inventory_status", "rego_input_key": "insurance_ai_model_inventory_status", "stability": "proposed", "description": "Governance status of an AI or predictive model within the insurer's AIS Program model inventory. The NAIC Model Bulletin requires all models to be documented before deployment in regulated insurance processes.", "permitted_values": [ "not_in_inventory_shadow_model", "registered_in_development", "validated_pending_deployment", "deployed_monitoring_active", "deployed_high_risk_enhanced_monitoring", "under_periodic_review", "material_change_pending_revalidation", "suspended_pending_investigation", "retired_decommissioned", "third_party_vendor_model_pending_assessment", "third_party_vendor_model_assessed_approved" ], "value_labels": { "not_in_inventory_shadow_model": "Not in Inventory Shadow Model", "registered_in_development": "Registered in Development", "validated_pending_deployment": "Validated Pending Deployment", "deployed_monitoring_active": "Deployed Monitoring Active", "deployed_high_risk_enhanced_monitoring": "Deployed High Risk Enhanced Monitoring", "under_periodic_review": "Under Periodic Review", "material_change_pending_revalidation": "Material Change Pending Revalidation", "suspended_pending_investigation": "Suspended Pending Investigation", "retired_decommissioned": "Retired Decommissioned", "third_party_vendor_model_pending_assessment": "Third Party Vendor Model Pending Assessment", "third_party_vendor_model_assessed_approved": "Third Party Vendor Model Assessed Approved" }, "regulatory_mappings": { "naic_model_bulletin": "AIS Program must maintain inventory of all AI systems used in regulated decisions", "colorado_reg_10_1_1": "Annual reporting must cover all ECDIS and predictive models in use", "ny_dfs_cl7_2024": "NY DFS expects documentation of all AI systems used in insurance operations" }, "use_case": "OPA rule: deny any agentic underwriting or claims decision where the dependent model status is not_in_inventory_shadow_model or third_party_vendor_model_pending_assessment.", "source": "NAIC Model Bulletin Section 3; Colorado Regulation 10-1-1" } ] }, { "subdomain": "Claims Intake, Triage & FNOL", "description": "First Notice of Loss (FNOL) and initial claims triage are the most active areas of agentic AI deployment in insurance as of 2026. Agents perform FNOL intake, coverage verification, initial severity scoring, and reservation setting. The NAIC Unfair Claims Settlement Practices Act (#900) governs timing and communication standards.", "acord_references": [ "ACORD 2.0 Claims XML", "ACORD ECOT (Claim Movement)", "ACORD GRLC Gen 2.0 Claims Handling & Orchestration" ], "categories": [ { "enum_name": "ClaimIntakeChannel", "label": "Claim Intake Channel", "otel_attribute": "insurance.claim.intake_channel", "opa_policy_path": "data.insurance.claim.intake_channel", "rego_input_key": "insurance_claim_intake_channel", "stability": "stable", "description": "Defines the allowed values for Claim Intake Channel in the Insurance: P&C, Life & Annuity catalog so OpenTelemetry spans and OPA policy inputs remain consistent across VeriProof. Terminology aligns to ACORD FNOL data standards; NAIC Unfair Claims Settlement Practices Act #900.", "permitted_values": [ "phone_call_center", "mobile_app_self_service", "web_portal", "ai_voice_agent", "ai_chat_agent", "agent_broker_submission", "repair_shop_direct", "hospital_direct_bill", "edi_direct_submission", "fax", "mail", "field_adjuster_initiated" ], "value_labels": { "phone_call_center": "Phone Call Center", "mobile_app_self_service": "Mobile App Self Service", "web_portal": "Web Portal", "ai_voice_agent": "AI Voice Agent", "ai_chat_agent": "AI Chat Agent", "agent_broker_submission": "Agent Broker Submission", "repair_shop_direct": "Repair Shop Direct", "hospital_direct_bill": "Hospital Direct Bill", "edi_direct_submission": "Edi Direct Submission", "fax": "Fax", "mail": "Mail", "field_adjuster_initiated": "Field Adjuster Initiated" }, "source": "ACORD FNOL data standards; NAIC Unfair Claims Settlement Practices Act #900" }, { "enum_name": "ClaimStatus", "label": "Claim Status", "otel_attribute": "insurance.claim.status", "opa_policy_path": "data.insurance.claim.status", "rego_input_key": "insurance_claim_status", "stability": "stable", "description": "The current processing status of an insurance claim across its full lifecycle.", "permitted_values": [ "fnol_received", "coverage_verification_in_progress", "coverage_verified", "coverage_denied_no_coverage", "investigation_in_progress", "inspection_scheduled", "inspection_complete", "medical_review_in_progress", "liability_investigation", "subrogation_evaluation", "reserve_established", "reserve_revised", "pending_documentation", "pending_medical_records", "pending_payment_authorization", "payment_issued", "closed_paid", "closed_no_payment", "closed_withdrawn", "reopened", "litigation_active", "arbitration_active", "appeal_pending" ], "value_labels": { "fnol_received": "Fnol Received", "coverage_verification_in_progress": "Coverage Verification in Progress", "coverage_verified": "Coverage Verified", "coverage_denied_no_coverage": "Coverage Denied No Coverage", "investigation_in_progress": "Investigation in Progress", "inspection_scheduled": "Inspection Scheduled", "inspection_complete": "Inspection Complete", "medical_review_in_progress": "Medical Review in Progress", "liability_investigation": "Liability Investigation", "subrogation_evaluation": "Subrogation Evaluation", "reserve_established": "Reserve Established", "reserve_revised": "Reserve Revised", "pending_documentation": "Pending Documentation", "pending_medical_records": "Pending Medical Records", "pending_payment_authorization": "Pending Payment Authorization", "payment_issued": "Payment Issued", "closed_paid": "Closed Paid", "closed_no_payment": "Closed No Payment", "closed_withdrawn": "Closed Withdrawn", "reopened": "Reopened", "litigation_active": "Litigation Active", "arbitration_active": "Arbitration Active", "appeal_pending": "Appeal Pending" }, "regulatory_mappings": { "naic_ucsp_900": "NAIC #900 — Unfair Claims Settlement Practices: acknowledgement within 10 days, decision within 30-45 days, payment within 10-30 days after agreement (state variations)", "california_fair_claims": "California Fair Claims Settlement Practices Regulations (10 CCR §2695)" }, "source": "ACORD Claims Lifecycle; NAIC Unfair Claims Settlement Practices Act #900" }, { "enum_name": "ClaimSeverityTier", "label": "Claim Severity Tier", "otel_attribute": "insurance.claim.severity_tier", "opa_policy_path": "data.insurance.claim.severity_tier", "rego_input_key": "insurance_claim_severity_tier", "stability": "proposed", "description": "Initial severity classification assigned by AI triage agent at FNOL. Determines routing — low-severity claims eligible for straight-through processing (STP); higher tiers require human adjuster involvement.", "permitted_values": [ "tier_1_express_stp_eligible", "tier_2_low_complexity", "tier_3_moderate_complexity", "tier_4_high_complexity", "tier_5_large_loss", "tier_6_catastrophe", "tier_7_casualty_bodily_injury", "tier_8_litigation_suspected", "tier_9_fraud_suspected", "tier_10_regulatory_sensitive" ], "value_labels": { "tier_1_express_stp_eligible": "Tier 1 — Express Stp Eligible", "tier_2_low_complexity": "Tier 2 — Low Complexity", "tier_3_moderate_complexity": "Tier 3 — Moderate Complexity", "tier_4_high_complexity": "Tier 4 — High Complexity", "tier_5_large_loss": "Tier 5 — Large Loss", "tier_6_catastrophe": "Tier 6 — Catastrophe", "tier_7_casualty_bodily_injury": "Tier 7 — Casualty Bodily Injury", "tier_8_litigation_suspected": "Tier 8 — Litigation Suspected", "tier_9_fraud_suspected": "Tier 9 — Fraud Suspected", "tier_10_regulatory_sensitive": "Tier 10 — Regulatory Sensitive" }, "ordered": true, "value_ordinals": { "tier_1_express_stp_eligible": 1, "tier_2_low_complexity": 2, "tier_3_moderate_complexity": 3, "tier_4_high_complexity": 4, "tier_5_large_loss": 5, "tier_6_catastrophe": 6, "tier_7_casualty_bodily_injury": 7, "tier_8_litigation_suspected": 8, "tier_9_fraud_suspected": 9, "tier_10_regulatory_sensitive": 10 }, "use_case": "OPA rule: route all tier_7 and above claims to human adjuster — block STP. Require HITL with senior_adjuster role for tier_8 and above. Require claims_compliance_officer for tier_10.", "source": "Industry claims triage best practices; NAIC Model Bulletin consumer harm severity framework; ACORD Claims handling standards" }, { "enum_name": "StraightThroughProcessingEligibility", "label": "Straight Through Processing Eligibility", "otel_attribute": "insurance.claim.stp_eligibility", "opa_policy_path": "data.insurance.claim.stp_eligibility", "rego_input_key": "insurance_claim_stp_eligibility", "stability": "proposed", "description": "Eligibility of a claim for autonomous straight-through processing without human adjuster involvement. The NAIC Model Bulletin requires that autonomous claims decisions that adversely affect consumers include appropriate human oversight.", "permitted_values": [ "eligible_fully_automated", "eligible_with_automated_rule_check", "ineligible_amount_exceeds_threshold", "ineligible_coverage_question", "ineligible_fraud_indicator", "ineligible_bodily_injury", "ineligible_litigation_indicator", "ineligible_catastrophe_loss", "ineligible_complex_liability", "ineligible_regulatory_sensitivity", "ineligible_prior_claims_pattern", "requires_human_review_before_payment" ], "value_labels": { "eligible_fully_automated": "Eligible Fully Automated", "eligible_with_automated_rule_check": "Eligible with Automated Rule Check", "ineligible_amount_exceeds_threshold": "Ineligible Amount Exceeds Threshold", "ineligible_coverage_question": "Ineligible Coverage Question", "ineligible_fraud_indicator": "Ineligible Fraud Indicator", "ineligible_bodily_injury": "Ineligible Bodily Injury", "ineligible_litigation_indicator": "Ineligible Litigation Indicator", "ineligible_catastrophe_loss": "Ineligible Catastrophe Loss", "ineligible_complex_liability": "Ineligible Complex Liability", "ineligible_regulatory_sensitivity": "Ineligible Regulatory Sensitivity", "ineligible_prior_claims_pattern": "Ineligible Prior Claims Pattern", "requires_human_review_before_payment": "Requires Human Review Before Payment" }, "regulatory_mappings": { "naic_model_bulletin": "AI claims systems must not result in unfair claims settlement practices under NAIC #900", "california_health_code_1367_01": "California Health & Safety Code §1367.01 — adverse health care determinations must be reviewed by licensed clinician, not solely by automated tool", "naic_ucsp_900": "NAIC #900 — Unfair Claims Settlement Practices Act: AI denials must meet same standards as human adjuster denials" }, "source": "NAIC Model Bulletin; ACORD GRLC Gen 2.0 Claims Handling; industry STP frameworks" } ] }, { "subdomain": "Claims Adjudication & Payment", "description": "Covers adjudication decisions, benefit determination, reserving, and payment processing. For health insurance, this subdomain also covers prior authorisation and coordination of benefits under HL7 FHIR Da Vinci standards. Adjudication decisions that adversely affect consumers are the most legally exposed area of insurance agentic AI.", "acord_references": [ "ACORD ECOT", "ACORD 2.0 Claims Payment" ], "fhir_resources": [ "ClaimResponse", "ExplanationOfBenefit", "CoverageEligibilityResponse" ], "categories": [ { "enum_name": "ClaimAdjudicationOutcome", "label": "Claim Adjudication Outcome", "otel_attribute": "insurance.claim.adjudication_outcome", "opa_policy_path": "data.insurance.claim.adjudication_outcome", "rego_input_key": "insurance_claim_adjudication_outcome", "stability": "stable", "description": "Defines the allowed values for Claim Adjudication Outcome in the Insurance: P&C, Life & Annuity catalog so OpenTelemetry spans and OPA policy inputs remain consistent across VeriProof. Terminology aligns to ACORD ECOT Claim Movement Standard; HL7 FHIR ClaimProcessingCodes; NAIC #900.", "permitted_values": [ "queued", "approved_full_payment", "approved_partial_payment", "approved_with_deductible_applied", "approved_with_coinsurance_applied", "approved_pending_proof_of_loss", "denied_no_coverage", "denied_policy_exclusion", "denied_late_reporting", "denied_fraud_suspected", "denied_claimant_liability", "denied_pre_existing_condition", "denied_medical_necessity", "denied_not_medically_necessary_ai", "denied_experimental_treatment", "contested_under_review", "settled_negotiated", "subrogated", "error_requires_correction", "partial_applied_coordination_of_benefits", "voided_reprocessing_required" ], "value_labels": { "queued": "Queued", "approved_full_payment": "Approved Full Payment", "approved_partial_payment": "Approved Partial Payment", "approved_with_deductible_applied": "Approved with Deductible Applied", "approved_with_coinsurance_applied": "Approved with Coinsurance Applied", "approved_pending_proof_of_loss": "Approved Pending Proof of Loss", "denied_no_coverage": "Denied No Coverage", "denied_policy_exclusion": "Denied Policy Exclusion", "denied_late_reporting": "Denied Late Reporting", "denied_fraud_suspected": "Denied Fraud Suspected", "denied_claimant_liability": "Denied Claimant Liability", "denied_pre_existing_condition": "Denied Pre Existing Condition", "denied_medical_necessity": "Denied Medical Necessity", "denied_not_medically_necessary_ai": "Denied not Medically Necessary AI", "denied_experimental_treatment": "Denied Experimental Treatment", "contested_under_review": "Contested Under Review", "settled_negotiated": "Settled Negotiated", "subrogated": "Subrogated", "error_requires_correction": "Error Requires Correction", "partial_applied_coordination_of_benefits": "Partial Applied Coordination of Benefits", "voided_reprocessing_required": "Voided Reprocessing Required" }, "regulatory_mappings": { "naic_ucsp_900": "NAIC #900 — All denial reasons must be documented and communicated in writing", "naic_model_bulletin": "AI-generated denial outcomes must be explainable and not constitute unfair claims settlement practices", "california_health_code": "§1367.01 — Health plan denial based solely on AI tool prohibited without clinician review", "aca_sec_2719": "ACA Section 2719 — Internal and external appeal processes for health plan adverse benefit determinations" }, "use_case": "OPA rule: block any autonomous denied_medical_necessity or denied_not_medically_necessary_ai outcome for health claims without licensed clinician review sign-off. Cite California Health & Safety Code §1367.01 and class action precedent (UnitedHealth/NaviHealth nH Predict).", "source": "ACORD ECOT Claim Movement Standard; HL7 FHIR ClaimProcessingCodes; NAIC #900" }, { "enum_name": "HealthClaimFHIROutcome", "label": "Health Claim FHIR Outcome", "otel_attribute": "insurance.health_claim.fhir_outcome", "opa_policy_path": "data.insurance.health_claim.fhir_outcome", "rego_input_key": "insurance_health_claim_fhir_outcome", "stability": "stable", "description": "HL7 FHIR ClaimResponse outcome codes used in electronic health claims adjudication. These are the exact code values from the FHIR ClaimProcessingCodes value set used in ClaimResponse and ExplanationOfBenefit resources.", "permitted_values": [ "queued", "complete", "error", "partial" ], "value_labels": { "queued": "Queued", "complete": "Complete", "error": "Error", "partial": "Partial" }, "code_definitions": { "queued": "The Claim/Pre-authorization/Pre-determination has been received but processing has not begun", "complete": "The processing has completed without errors", "error": "One or more errors have been detected in the Claim", "partial": "No errors have been detected in the Claim and some of the adjudication has been performed" }, "source": "HL7 FHIR v6.0 ClaimProcessingCodes value set; ClaimResponse resource", "source_url": "http://build.fhir.org/valueset-claim-outcome.html" }, { "enum_name": "PriorAuthorizationStatus", "label": "Prior Authorization Status", "otel_attribute": "insurance.prior_auth.status", "opa_policy_path": "data.insurance.prior_auth.status", "rego_input_key": "insurance_prior_auth_status", "stability": "stable", "description": "Status of a health insurance prior authorisation request. CMS Interoperability and Prior Authorization Final Rule (2024) mandates 72-hour response for expedited requests and 7-day response for standard requests. Agentic AI is the primary mechanism for meeting these deadlines.", "permitted_values": [ "received_pending_review", "information_requested_incomplete", "clinical_criteria_review_in_progress", "peer_to_peer_review_requested", "approved", "approved_with_modifications", "denied_not_medically_necessary", "denied_experimental_investigational", "denied_benefit_exhausted", "denied_not_covered", "denied_requires_step_therapy", "partial_approval", "cancelled_by_provider", "expired", "appeal_pending", "appeal_approved", "appeal_denied", "external_review_requested" ], "value_labels": { "received_pending_review": "Received Pending Review", "information_requested_incomplete": "Information Requested Incomplete", "clinical_criteria_review_in_progress": "Clinical Criteria Review in Progress", "peer_to_peer_review_requested": "Peer to Peer Review Requested", "approved": "Approved", "approved_with_modifications": "Approved with Modifications", "denied_not_medically_necessary": "Denied not Medically Necessary", "denied_experimental_investigational": "Denied Experimental Investigational", "denied_benefit_exhausted": "Denied Benefit Exhausted", "denied_not_covered": "Denied not Covered", "denied_requires_step_therapy": "Denied Requires Step Therapy", "partial_approval": "Partial Approval", "cancelled_by_provider": "Cancelled by Provider", "expired": "Expired", "appeal_pending": "Appeal Pending", "appeal_approved": "Appeal Approved", "appeal_denied": "Appeal Denied", "external_review_requested": "External Review Requested" }, "regulatory_mappings": { "cms_prior_auth_final_rule": "CMS Interoperability and Prior Authorization Final Rule (2024): 72 hours for expedited, 7 calendar days for standard PA decisions", "aca_sec_2719": "ACA §2719 — Internal appeal rights for adverse benefit determinations", "california_health_code_1367_01": "§1367.01 — Adverse determinations require licensed clinician review, not solely automated tools", "hl7_davinci_pas": "HL7 Da Vinci Prior Authorization Support (PAS) Implementation Guide — FHIR-based e-PA submission" }, "use_case": "OPA rule: block autonomous denial_not_medically_necessary or denial_experimental_investigational outcomes without documented licensed_clinician_reviewer approval. Block any PA decision that exceeds 72h (expedited) or 7 days (standard) SLA without escalation.", "source": "CMS Prior Authorization Final Rule; HL7 Da Vinci PAS IG; California Health & Safety Code §1367.01" }, { "enum_name": "ReserveChangeReason", "label": "Reserve Change Reason", "otel_attribute": "insurance.claim.reserve_change_reason", "opa_policy_path": "data.insurance.claim.reserve_change_reason", "rego_input_key": "insurance_claim_reserve_change_reason", "stability": "proposed", "description": "Reason for a change to a claim reserve. Agentic reserving agents must document every reserve change for actuarial review and Solvency II / ORSA adequacy assessment.", "permitted_values": [ "initial_establishment", "new_medical_information", "liability_reassessment", "attorney_involvement", "litigation_filed", "settlement_negotiation", "coverage_dispute_resolved", "additional_damages_identified", "damages_revised_downward", "subrogation_recovery_expected", "salvage_recovery_expected", "catastrophe_event_development", "actuarial_ibnr_adjustment", "regulatory_requirement", "claim_closure", "reopen_following_closure" ], "value_labels": { "initial_establishment": "Initial Establishment", "new_medical_information": "New Medical Information", "liability_reassessment": "Liability Reassessment", "attorney_involvement": "Attorney Involvement", "litigation_filed": "Litigation Filed", "settlement_negotiation": "Settlement Negotiation", "coverage_dispute_resolved": "Coverage Dispute Resolved", "additional_damages_identified": "Additional Damages Identified", "damages_revised_downward": "Damages Revised Downward", "subrogation_recovery_expected": "Subrogation Recovery Expected", "salvage_recovery_expected": "Salvage Recovery Expected", "catastrophe_event_development": "Catastrophe Event Development", "actuarial_ibnr_adjustment": "Actuarial Ibnr Adjustment", "regulatory_requirement": "Regulatory Requirement", "claim_closure": "Claim Closure", "reopen_following_closure": "Reopen Following Closure" }, "source": "ACORD Reserving standards; NAIC Annual Statement instructions; Solvency II technical provisions requirements" } ] }, { "subdomain": "Fraud Detection & Special Investigations", "description": "Covers AI-driven insurance fraud detection, scoring, and Special Investigations Unit (SIU) referrals. The NAIC #900 and state fraud regulations govern investigation timelines and mandatory reporting requirements.", "categories": [ { "enum_name": "FraudIndicatorType", "label": "Fraud Indicator Type", "otel_attribute": "insurance.fraud.indicator_type", "opa_policy_path": "data.insurance.fraud.indicator_type", "rego_input_key": "insurance_fraud_indicator_type", "stability": "stable", "description": "Types of fraud indicators detected by agentic AI fraud scoring systems. These categorise the nature of suspected fraud for SIU routing.", "permitted_values": [ "staged_accident", "inflated_injury_claim", "soft_tissue_fraud_ring", "medical_provider_billing_fraud", "phantom_treatment_upcoding", "arson_property_fraud", "water_damage_staged", "identity_theft_application", "premium_fraud_misrepresentation", "workers_comp_malingering", "workers_comp_provider_fraud", "vehicle_theft_staged", "life_insurance_premium_diversion", "annuity_senior_fraud", "viatical_settlement_fraud", "catastrophe_fraud_post_event", "coordinated_fraud_ring", "digital_manipulation_evidence" ], "value_labels": { "staged_accident": "Staged Accident", "inflated_injury_claim": "Inflated Injury Claim", "soft_tissue_fraud_ring": "Soft Tissue Fraud Ring", "medical_provider_billing_fraud": "Medical Provider Billing Fraud", "phantom_treatment_upcoding": "Phantom Treatment Upcoding", "arson_property_fraud": "Arson Property Fraud", "water_damage_staged": "Water Damage Staged", "identity_theft_application": "Identity Theft Application", "premium_fraud_misrepresentation": "Premium Fraud Misrepresentation", "workers_comp_malingering": "Workers Comp Malingering", "workers_comp_provider_fraud": "Workers Comp Provider Fraud", "vehicle_theft_staged": "Vehicle Theft Staged", "life_insurance_premium_diversion": "Life Insurance Premium Diversion", "annuity_senior_fraud": "Annuity Senior Fraud", "viatical_settlement_fraud": "Viatical Settlement Fraud", "catastrophe_fraud_post_event": "Catastrophe Fraud Post Event", "coordinated_fraud_ring": "Coordinated Fraud Ring", "digital_manipulation_evidence": "Digital Manipulation Evidence" }, "source": "NICB (National Insurance Crime Bureau) fraud typologies; ACFE insurance fraud categories; IASIU investigation standards" }, { "enum_name": "FraudCaseStatus", "label": "Fraud Case Status", "otel_attribute": "insurance.fraud.case_status", "opa_policy_path": "data.insurance.fraud.case_status", "rego_input_key": "insurance_fraud_case_status", "stability": "stable", "description": "Lifecycle state of an insurance fraud investigation from model score generation through SIU referral, law-enforcement escalation, and final resolution.", "permitted_values": [ "score_generated_monitoring", "threshold_exceeded_siu_referral_pending", "siu_referral_submitted", "siu_investigation_in_progress", "additional_documentation_requested", "law_enforcement_referral", "state_fraud_bureau_referral", "prosecution_referred", "fraud_confirmed_claim_denied", "fraud_confirmed_policy_rescinded", "fraud_unconfirmed_claim_paid", "closed_false_positive", "civil_recovery_initiated" ], "value_labels": { "score_generated_monitoring": "Score Generated - Monitoring", "threshold_exceeded_siu_referral_pending": "Threshold Exceeded - SIU Referral Pending", "siu_referral_submitted": "SIU Referral Submitted", "siu_investigation_in_progress": "SIU Investigation In Progress", "additional_documentation_requested": "Additional Documentation Requested", "law_enforcement_referral": "Law Enforcement Referral", "state_fraud_bureau_referral": "State Fraud Bureau Referral", "prosecution_referred": "Prosecution Referred", "fraud_confirmed_claim_denied": "Fraud Confirmed Claim Denied", "fraud_confirmed_policy_rescinded": "Fraud Confirmed Policy Rescinded", "fraud_unconfirmed_claim_paid": "Fraud Unconfirmed Claim Paid", "closed_false_positive": "Closed False Positive", "civil_recovery_initiated": "Civil Recovery Initiated" }, "regulatory_mappings": { "state_fraud_reporting": "Most states mandate SIU referral to state fraud bureau within 30-60 days of confirmed fraud discovery", "naic_model_fraud_investigation": "NAIC Model Fraud Investigation Plan requirements" }, "source": "NICB SIU referral standards; NAIC insurance fraud model act" }, { "enum_name": "ClaimFraudRiskScore", "label": "Claim Fraud Risk Score", "otel_attribute": "insurance.fraud.risk_score_tier", "opa_policy_path": "data.insurance.fraud.risk_score_tier", "rego_input_key": "insurance_fraud_risk_score_tier", "stability": "proposed", "description": "Ordinal risk tier derived from the AI fraud scoring model. Used to gate STP eligibility and SIU routing without exposing proprietary model scores.", "permitted_values": [ "tier_1_very_low_risk", "tier_2_low_risk", "tier_3_moderate_risk_enhanced_review", "tier_4_high_risk_siu_evaluation", "tier_5_very_high_risk_siu_referral_mandatory" ], "value_labels": { "tier_1_very_low_risk": "Tier 1 — Very Low Risk", "tier_2_low_risk": "Tier 2 — Low Risk", "tier_3_moderate_risk_enhanced_review": "Tier 3 — Moderate Risk Enhanced Review", "tier_4_high_risk_siu_evaluation": "Tier 4 — High Risk SIU Evaluation", "tier_5_very_high_risk_siu_referral_mandatory": "Tier 5 — Very High Risk SIU Referral Mandatory" }, "ordered": true, "value_ordinals": { "tier_1_very_low_risk": 1, "tier_2_low_risk": 2, "tier_3_moderate_risk_enhanced_review": 3, "tier_4_high_risk_siu_evaluation": 4, "tier_5_very_high_risk_siu_referral_mandatory": 5 }, "regulatory_mappings": { "naic_model_bulletin": "Fraud detection AI models must be included in AIS Program and documented for governance", "colorado_reg_10_1_1": "Fraud scoring models using ECDIS require bias testing for disparate impact" }, "source": "Industry claims fraud management best practices; ACFE insurance fraud scoring frameworks" } ] }, { "subdomain": "Life & Annuity Underwriting", "description": "Covers AI-specific life insurance and annuity underwriting workflows. The NAIC Model Bulletin Section 3 and Colorado Regulation 10-1-1 apply directly. Accelerated Underwriting (AUW) programs using AI have materially changed the L&A underwriting workflow.", "acord_references": [ "ACORD OLI/TXLife", "ACORD Life Application XML" ], "categories": [ { "enum_name": "LifeUnderwritingMethod", "label": "Life Underwriting Method", "otel_attribute": "insurance.life.underwriting_method", "opa_policy_path": "data.insurance.life.underwriting_method", "rego_input_key": "insurance_life_underwriting_method", "stability": "stable", "description": "The underwriting approach used for a life or annuity application. Accelerated underwriting programs using AI have grown to cover the majority of eligible applications at major carriers.", "permitted_values": [ "fully_underwritten_fluid", "fully_underwritten_non_fluid", "accelerated_underwriting_auw", "simplified_issue_no_exam", "guaranteed_issue", "table_shave_credit", "jumbo_line_facultative_reinsurance", "group_benefits_pooled", "group_continuation_evidence_of_insurability", "final_expense_graded_benefit" ], "value_labels": { "fully_underwritten_fluid": "Fully Underwritten Fluid", "fully_underwritten_non_fluid": "Fully Underwritten Non Fluid", "accelerated_underwriting_auw": "Accelerated Underwriting Auw", "simplified_issue_no_exam": "Simplified Issue No Exam", "guaranteed_issue": "Guaranteed Issue", "table_shave_credit": "Table Shave Credit", "jumbo_line_facultative_reinsurance": "Jumbo Line Facultative Reinsurance", "group_benefits_pooled": "Group Benefits Pooled", "group_continuation_evidence_of_insurability": "Group Continuation Evidence of Insurability", "final_expense_graded_benefit": "Final Expense Graded Benefit" }, "regulatory_mappings": { "colorado_reg_10_1_1": "Accelerated underwriting models using ECDIS require bias testing and annual reporting", "naic_model_bulletin": "All AUW AI systems require AIS Program documentation" }, "source": "LIMRA Accelerated Underwriting Research; ACORD Life Application standards; Colorado Division of Insurance" }, { "enum_name": "MortalityRatingClass", "label": "Mortality Rating Class", "otel_attribute": "insurance.life.mortality_rating_class", "opa_policy_path": "data.insurance.life.mortality_rating_class", "rego_input_key": "insurance_life_mortality_rating_class", "stability": "stable", "description": "Standard life insurance mortality rating classification. The AI underwriting model output must map to one of these standardised classes for actuarial and state rate filing purposes.", "permitted_values": [ "preferred_plus", "preferred", "preferred_non_tobacco", "standard_plus", "standard", "standard_tobacco", "substandard_table_a", "substandard_table_b", "substandard_table_c", "substandard_table_d", "substandard_table_e", "substandard_table_f", "substandard_table_g", "substandard_table_h", "flat_extra", "postponed", "declined" ], "value_labels": { "preferred_plus": "Preferred Plus", "preferred": "Preferred", "preferred_non_tobacco": "Preferred Non Tobacco", "standard_plus": "Standard Plus", "standard": "Standard", "standard_tobacco": "Standard Tobacco", "substandard_table_a": "Substandard Table a", "substandard_table_b": "Substandard Table B", "substandard_table_c": "Substandard Table C", "substandard_table_d": "Substandard Table D", "substandard_table_e": "Substandard Table E", "substandard_table_f": "Substandard Table F", "substandard_table_g": "Substandard Table G", "substandard_table_h": "Substandard Table H", "flat_extra": "Flat Extra", "postponed": "Postponed", "declined": "Declined" }, "source": "Standard industry mortality rating classes; ACORD OLI Life Application; Society of Actuaries mortality studies" }, { "enum_name": "AnnuitySurrenderChargeStatus", "label": "Annuity Surrender Charge Status", "otel_attribute": "insurance.annuity.surrender_charge_status", "opa_policy_path": "data.insurance.annuity.surrender_charge_status", "rego_input_key": "insurance_annuity_surrender_charge_status", "stability": "stable", "description": "Surrender charge status for annuity contracts. Agentic annuity service agents must correctly classify surrender charge status before processing any full or partial surrender request.", "permitted_values": [ "within_surrender_charge_period", "free_withdrawal_available", "free_withdrawal_exhausted", "surrender_charge_period_expired", "nursing_home_waiver_eligible", "terminal_illness_waiver_eligible", "required_minimum_distribution_exempt", "annuitisation_no_surrender_charge" ], "value_labels": { "within_surrender_charge_period": "Within Surrender Charge Period", "free_withdrawal_available": "Free Withdrawal Available", "free_withdrawal_exhausted": "Free Withdrawal Exhausted", "surrender_charge_period_expired": "Surrender Charge Period Expired", "nursing_home_waiver_eligible": "Nursing Home Waiver Eligible", "terminal_illness_waiver_eligible": "Terminal Illness Waiver Eligible", "required_minimum_distribution_exempt": "Required Minimum Distribution Exempt", "annuitisation_no_surrender_charge": "Annuitisation No Surrender Charge" }, "regulatory_mappings": { "naic_annuity_suitability": "NAIC Suitability in Annuity Transactions Model Regulation #275 — best interest standard", "sec_reg_bi": "SEC Regulation Best Interest — applies to variable annuity recommendations", "dol_fiduciary_rule": "DOL Fiduciary Rule (2024) — best interest standard for retirement account annuity transactions" }, "source": "ACORD TXLife annuity transaction types; NAIC #275 Annuity Suitability Model Regulation" } ] }, { "subdomain": "Subrogation & Recoveries", "description": "Covers AI-driven subrogation opportunity identification, recovery pursuit, and settlement. Agentic AI processes claim data against liability evidence to score subrogation potential and initiate recovery workflows autonomously.", "categories": [ { "enum_name": "SubrogationOpportunityStatus", "label": "Subrogation Opportunity Status", "otel_attribute": "insurance.subrogation.opportunity_status", "opa_policy_path": "data.insurance.subrogation.opportunity_status", "rego_input_key": "insurance_subrogation_opportunity_status", "stability": "stable", "description": "Defines the allowed values for Subrogation Opportunity Status in the Insurance: P&C, Life & Annuity catalog so OpenTelemetry spans and OPA policy inputs remain consistent across VeriProof. Terminology aligns to ACORD Subrogation workflow standards; NASP (National Association of Subrogation Professionals) best practices.", "permitted_values": [ "no_subrogation_potential", "potential_identified_evaluation_in_progress", "opportunity_confirmed_demand_pending", "demand_issued", "demand_disputed", "arbitration_filed", "intercompany_arbitration_pending", "partial_recovery_received", "full_recovery_received", "recovery_exhausted_closed", "statute_of_limitations_expired", "waived_settlement_agreement" ], "value_labels": { "no_subrogation_potential": "No Subrogation Potential", "potential_identified_evaluation_in_progress": "Potential Identified Evaluation in Progress", "opportunity_confirmed_demand_pending": "Opportunity Confirmed Demand Pending", "demand_issued": "Demand Issued", "demand_disputed": "Demand Disputed", "arbitration_filed": "Arbitration Filed", "intercompany_arbitration_pending": "Intercompany Arbitration Pending", "partial_recovery_received": "Partial Recovery Received", "full_recovery_received": "Full Recovery Received", "recovery_exhausted_closed": "Recovery Exhausted Closed", "statute_of_limitations_expired": "Statute of Limitations Expired", "waived_settlement_agreement": "Waived Settlement Agreement" }, "source": "ACORD Subrogation workflow standards; NASP (National Association of Subrogation Professionals) best practices" }, { "enum_name": "SubrogationLiabilityBasis", "label": "Subrogation Liability Basis", "otel_attribute": "insurance.subrogation.liability_basis", "opa_policy_path": "data.insurance.subrogation.liability_basis", "rego_input_key": "insurance_subrogation_liability_basis", "stability": "proposed", "description": "Defines the allowed values for Subrogation Liability Basis in the Insurance: P&C, Life & Annuity catalog so OpenTelemetry spans and OPA policy inputs remain consistent across VeriProof. Terminology aligns to NASP subrogation categorisation; reinsurance treaty subrogation articles.", "permitted_values": [ "negligence_third_party", "product_liability", "premises_liability", "workers_compensation_employer_negligence", "medical_malpractice", "auto_liability_at_fault", "auto_liability_uninsured_motorist", "auto_liability_underinsured_motorist", "dram_shop_liability", "government_entity_liability", "contract_breach_warranty", "no_liability_basis" ], "value_labels": { "negligence_third_party": "Negligence Third Party", "product_liability": "Product Liability", "premises_liability": "Premises Liability", "workers_compensation_employer_negligence": "Workers Compensation Employer Negligence", "medical_malpractice": "Medical Malpractice", "auto_liability_at_fault": "Auto Liability At Fault", "auto_liability_uninsured_motorist": "Auto Liability Uninsured Motorist", "auto_liability_underinsured_motorist": "Auto Liability Underinsured Motorist", "dram_shop_liability": "Dram Shop Liability", "government_entity_liability": "Government Entity Liability", "contract_breach_warranty": "Contract Breach Warranty", "no_liability_basis": "No Liability Basis" }, "source": "NASP subrogation categorisation; reinsurance treaty subrogation articles" } ] }, { "subdomain": "Reinsurance & Specialty Markets", "description": "Covers reinsurance cession, placement, and settlement workflows. ACORD GRLC Generation 2.0 (released April 2025) is the current digital standard, built on the Lloyd's Blueprint Two Core Data Record (CDR). Agentic AI assists with bordereau processing, premium allocation, and claims bordereaux.", "acord_references": [ "ACORD GRLC Gen 2.0", "ACORD ECOT", "ACORD EBOT", "ACORD CRP", "Lloyd's CDR" ], "categories": [ { "enum_name": "ReinsuranceTreatyType", "label": "Reinsurance Treaty Type", "otel_attribute": "insurance.reinsurance.treaty_type", "opa_policy_path": "data.insurance.reinsurance.treaty_type", "rego_input_key": "insurance_reinsurance_treaty_type", "stability": "stable", "description": "Defines the allowed values for Reinsurance Treaty Type in the Insurance: P&C, Life & Annuity catalog so OpenTelemetry spans and OPA policy inputs remain consistent across VeriProof. Terminology aligns to ACORD GRLC Gen 2.0 Treaty Classification; Munich Re / Swiss Re reinsurance taxonomy.", "permitted_values": [ "quota_share", "surplus_share", "excess_of_loss_per_risk", "excess_of_loss_per_occurrence", "aggregate_stop_loss", "catastrophe_excess_of_loss", "facultative_obligatory", "facultative_risk", "finite_risk", "parametric", "industry_loss_warranty" ], "value_labels": { "quota_share": "Quota Share", "surplus_share": "Surplus Share", "excess_of_loss_per_risk": "Excess of Loss Per Risk", "excess_of_loss_per_occurrence": "Excess of Loss Per Occurrence", "aggregate_stop_loss": "Aggregate Stop Loss", "catastrophe_excess_of_loss": "Catastrophe Excess of Loss", "facultative_obligatory": "Facultative Obligatory", "facultative_risk": "Facultative Risk", "finite_risk": "Finite Risk", "parametric": "Parametric", "industry_loss_warranty": "Industry Loss Warranty" }, "source": "ACORD GRLC Gen 2.0 Treaty Classification; Munich Re / Swiss Re reinsurance taxonomy" }, { "enum_name": "PlacingStatus", "label": "Placing Status", "otel_attribute": "insurance.reinsurance.placing_status", "opa_policy_path": "data.insurance.reinsurance.placing_status", "rego_input_key": "insurance_reinsurance_placing_status", "stability": "stable", "description": "Status of reinsurance risk placement using the ACORD GRLC Gen 2.0 Unified Placing Standard.", "permitted_values": [ "submission_prepared", "submission_sent_to_market", "indication_received", "firm_order_placed", "firm_order_accepted", "partially_placed", "fully_placed", "binding_confirmed", "contract_documentation_pending", "contract_signed", "premium_awaiting_settlement", "declined", "withdrawn" ], "value_labels": { "submission_prepared": "Submission Prepared", "submission_sent_to_market": "Submission Sent to Market", "indication_received": "Indication Received", "firm_order_placed": "Firm Order Placed", "firm_order_accepted": "Firm Order Accepted", "partially_placed": "Partially Placed", "fully_placed": "Fully Placed", "binding_confirmed": "Binding Confirmed", "contract_documentation_pending": "Contract Documentation Pending", "contract_signed": "Contract Signed", "premium_awaiting_settlement": "Premium Awaiting Settlement", "declined": "Declined", "withdrawn": "Withdrawn" }, "source": "ACORD GRLC Generation 2.0 Unified Placing Standard; Lloyd's Blueprint Two CDR", "source_url": "https://acord.org/ACORD-about/acord-news/2025/04/10/acord-launches-grlc-generation-2.0-data-standards" }, { "enum_name": "CatastropheModelType", "label": "Catastrophe Model Type", "otel_attribute": "insurance.catastrophe.model_type", "opa_policy_path": "data.insurance.catastrophe.model_type", "rego_input_key": "insurance_catastrophe_model_type", "stability": "proposed", "description": "Type of catastrophe model used for risk accumulation analysis, rate adequacy testing, and reinsurance purchasing. AI agents assisting with cat model execution must tag which model platform produced the output.", "permitted_values": [ "rms_risksmartstorm", "air_touchstone", "karen_clark_kcc", "corelogic_cat", "verisk_cat", "proprietary_internal_model", "deterministic_scenario", "climate_change_adjusted", "oecd_hazard_model", "parametric_trigger_model" ], "value_labels": { "rms_risksmartstorm": "Rms Risksmartstorm", "air_touchstone": "Air Touchstone", "karen_clark_kcc": "Karen Clark Kcc", "corelogic_cat": "Corelogic CAT", "verisk_cat": "Verisk CAT", "proprietary_internal_model": "Proprietary Internal Model", "deterministic_scenario": "Deterministic Scenario", "climate_change_adjusted": "Climate Change Adjusted", "oecd_hazard_model": "Oecd Hazard Model", "parametric_trigger_model": "Parametric Trigger Model" }, "regulatory_mappings": { "naic_orsa": "NAIC ORSA Model Act #505 — Own Risk and Solvency Assessment: catastrophe risk must be modelled and documented", "solvency_ii": "Solvency II SCR natural catastrophe sub-module or approved internal model" }, "source": "Lloyd's Catastrophe Model validation standards; NAIC ORSA guidance" } ] }, { "subdomain": "Regulatory Compliance & Market Conduct", "description": "Covers AI governance documentation, bias testing compliance, and market conduct examination readiness. The NAIC Model Bulletin and Colorado Regulation 10-1-1 are the primary compliance frameworks as of March 2026.", "categories": [ { "enum_name": "NAICAISProgramStatus", "label": "NAIC AIS Program Status", "otel_attribute": "insurance.ai_governance.ais_program_status", "opa_policy_path": "data.insurance.ai_governance.ais_program_status", "rego_input_key": "insurance_ai_governance_ais_program_status", "stability": "stable", "description": "Governance status of the insurer's AI System (AIS) Program required by the NAIC Model Bulletin. 24 states had adopted the Model Bulletin as of March 2025.", "permitted_values": [ "program_not_established", "program_in_development", "program_established_pending_board_approval", "program_active_board_approved", "program_under_annual_review", "program_updated_post_review", "program_deficient_regulatory_finding", "program_remediation_in_progress", "market_conduct_examination_in_progress" ], "value_labels": { "program_not_established": "Program not Established", "program_in_development": "Program in Development", "program_established_pending_board_approval": "Program Established Pending Board Approval", "program_active_board_approved": "Program Active Board Approved", "program_under_annual_review": "Program Under Annual Review", "program_updated_post_review": "Program Updated Post Review", "program_deficient_regulatory_finding": "Program Deficient Regulatory Finding", "program_remediation_in_progress": "Program Remediation in Progress", "market_conduct_examination_in_progress": "Market Conduct Examination in Progress" }, "regulatory_mappings": { "naic_model_bulletin": "NAIC Model Bulletin requires documented AIS Program covering governance, risk management, consumer notice, vendor management", "state_market_conduct": "State insurance departments may request AIS Program documentation during market conduct examinations" }, "source": "NAIC Model Bulletin: Use of Artificial Intelligence Systems by Insurers (December 2023)", "source_url": "https://content.naic.org/sites/default/files/inline-files/2023-12-4%20Model%20Bulletin_Adopted_0.pdf" }, { "enum_name": "InsuranceAIConsumerNoticeStatus", "label": "Insurance AI Consumer Notice Status", "otel_attribute": "insurance.ai_governance.consumer_notice_status", "opa_policy_path": "data.insurance.ai_governance.consumer_notice_status", "rego_input_key": "insurance_ai_governance_consumer_notice_status", "stability": "proposed", "description": "Status of consumer notification that AI systems are in use at the relevant stage of the insurance lifecycle. The NAIC Model Bulletin requires consumers to receive notice and access to appropriate information.", "permitted_values": [ "notice_not_required_no_ai_used", "notice_required_pending", "notice_delivered_application", "notice_delivered_underwriting_decision", "notice_delivered_claims_decision", "notice_delivered_adverse_action", "notice_delivered_rate_change", "appeal_rights_communicated", "notice_disputed_by_consumer" ], "value_labels": { "notice_not_required_no_ai_used": "Notice not Required No AI Used", "notice_required_pending": "Notice Required Pending", "notice_delivered_application": "Notice Delivered Application", "notice_delivered_underwriting_decision": "Notice Delivered Underwriting Decision", "notice_delivered_claims_decision": "Notice Delivered Claims Decision", "notice_delivered_adverse_action": "Notice Delivered Adverse Action", "notice_delivered_rate_change": "Notice Delivered Rate Change", "appeal_rights_communicated": "Appeal Rights Communicated", "notice_disputed_by_consumer": "Notice Disputed by Consumer" }, "regulatory_mappings": { "naic_model_bulletin": "Consumers should receive notice that AI is in use and access to appropriate information at each lifecycle stage", "california_health_code": "California requires disclosure when AI contributes to health care coverage decisions" }, "source": "NAIC Model Bulletin Section 3 — Consumer Notice requirements" }, { "enum_name": "StateAIInsuranceRegulationApplicability", "label": "State AI Insurance Regulation Applicability", "otel_attribute": "insurance.ai_governance.state_regulation", "opa_policy_path": "data.insurance.ai_governance.state_regulation", "rego_input_key": "insurance_ai_governance_state_regulation", "stability": "stable", "description": "The specific state AI insurance regulation or guidance applicable to this insurer and AI system deployment. Used to determine which additional compliance obligations apply beyond the NAIC Model Bulletin baseline.", "permitted_values": [ "naic_model_bulletin_baseline", "colorado_reg_10_1_1_life", "colorado_reg_10_1_1_auto", "colorado_reg_10_1_1_health", "new_york_dfs_circular_letter_7_2024", "california_health_code_1367_01", "california_cppa_draft_ai_regulations", "washington_state_insurance_ai_guidance", "illinois_insurance_ai_guidance", "connecticut_insurance_ai_bulletin", "multiple_state_requirements_apply" ], "value_labels": { "naic_model_bulletin_baseline": "NAIC Model Bulletin Baseline", "colorado_reg_10_1_1_life": "Colorado Reg 10 1 1 Life", "colorado_reg_10_1_1_auto": "Colorado Reg 10 1 1 Auto", "colorado_reg_10_1_1_health": "Colorado Reg 10 1 1 Health", "new_york_dfs_circular_letter_7_2024": "New York Dfs Circular Letter 7 2024", "california_health_code_1367_01": "California Health Code 1367 01", "california_cppa_draft_ai_regulations": "California Cppa Draft AI Regulations", "washington_state_insurance_ai_guidance": "Washington State Insurance AI Guidance", "illinois_insurance_ai_guidance": "Illinois Insurance AI Guidance", "connecticut_insurance_ai_bulletin": "Connecticut Insurance AI Bulletin", "multiple_state_requirements_apply": "Multiple State Requirements Apply" }, "source": "Fenwick LLP Insurance AI Regulation Tracker (December 2025); NAIC State Adoption Matrix", "source_url": "https://www.fenwick.com/insights/publications/tracking-the-evolution-of-ai-insurance-regulation" } ] } ], "opa_rego_policy_patterns": { "description": "Insurance-specific OPA Rego policy patterns referencing enum values from this file and from 00_core_sdk_and_governance.json. Illustrative patterns, not production policies.", "patterns": [ { "pattern_id": "insurance.block_autonomous_health_claim_denial_without_clinician_review", "pattern_name": "block_autonomous_health_claim_denial_without_clinician_review", "enforcement_effect": "deny", "description": "Block any AI agent from autonomously issuing a health claim denial based on medical necessity without a licensed clinician having reviewed and approved the decision. Directly addresses UnitedHealth/NaviHealth nH Predict litigation and California Health & Safety Code §1367.01.", "applicable_enums": [ "ClaimAdjudicationOutcome", "StraightThroughProcessingEligibility", "HumanOversightDecision" ], "regulatory_basis": "California Health & Safety Code §1367.01; NAIC Unfair Claims Settlement Practices Act #900; CMS Prior Authorization Final Rule (2024)", "rego_sketch": "package insurance.claims\n\nclinician_required_outcomes := {\n \"denied_medical_necessity\",\n \"denied_not_medically_necessary_ai\",\n \"denied_experimental_treatment\",\n \"denied_pre_existing_condition\"\n}\n\ndeny[msg] {\n input.insurance_claim_adjudication_outcome in clinician_required_outcomes\n input.gen_ai_agent_autonomy_level in {\"supervised_autonomous\", \"fully_autonomous\"}\n input.insurance_hitl_reviewer_role != \"licensed_clinician\"\n msg := \"California Health Code §1367.01 / NAIC #900 violation: Medical necessity denial requires documented licensed clinician review — autonomous AI-only denial is prohibited\"\n}" }, { "pattern_id": "insurance.require_ecdis_bias_test_before_model_deployment", "pattern_name": "require_ecdis_bias_test_before_model_deployment", "enforcement_effect": "deny", "description": "Block deployment of any underwriting or rating model that uses ECDIS (External Consumer Data and Information Sources) unless the model has completed required bias testing under Colorado Regulation 10-1-1 and the NAIC Model Bulletin.", "applicable_enums": [ "ECDISBiasTestOutcome", "InsuranceAIModelInventoryStatus", "InsuranceLineOfBusiness" ], "regulatory_basis": "Colorado SB21-169 / Regulation 10-1-1 (effective Oct 15, 2025); NAIC Model Bulletin (24 states as of March 2025)", "rego_sketch": "package insurance.underwriting\n\nlines_requiring_co_bias_test := {\n \"term_life\",\n \"whole_life\",\n \"universal_life\",\n \"personal_auto\",\n \"health_individual\",\n \"health_group\",\n \"medicare_advantage\"\n}\n\nblocking_bias_statuses := {\n \"testing_not_yet_performed\",\n \"material_disparity_corrective_action_pending\",\n \"model_suspended_pending_remediation\",\n \"test_failed_methodology_issue\"\n}\n\ndeny[msg] {\n input.insurance_policy_line_of_business in lines_requiring_co_bias_test\n input.insurance_underwriting_ecdis_bias_test_outcome in blocking_bias_statuses\n msg := sprintf(\"Colorado Reg 10-1-1 violation: ECDIS bias test status '%v' blocks model deployment for regulated line '%v'. Annual compliance report required.\", [input.insurance_underwriting_ecdis_bias_test_outcome, input.insurance_policy_line_of_business])\n}" }, { "pattern_id": "insurance.enforce_prior_auth_response_time_sla", "pattern_name": "enforce_prior_auth_response_time_sla", "enforcement_effect": "deny", "description": "Alert and escalate when a prior authorisation request approaches the CMS-mandated response deadline — 72 hours for expedited requests, 7 calendar days for standard requests.", "applicable_enums": [ "PriorAuthorizationStatus", "ClaimSeverityTier" ], "regulatory_basis": "CMS Interoperability and Prior Authorization Final Rule (2024) — 72-hour and 7-day PA response mandates", "rego_sketch": "package insurance.prior_auth\n\ndefault sla_breached = false\n\nsla_breached {\n input.prior_auth_type == \"expedited\"\n input.hours_elapsed_since_receipt > 72\n input.insurance_prior_auth_status in {\"received_pending_review\", \"clinical_criteria_review_in_progress\"}\n}\n\nsla_breached {\n input.prior_auth_type == \"standard\"\n input.calendar_days_elapsed > 7\n input.insurance_prior_auth_status in {\"received_pending_review\", \"clinical_criteria_review_in_progress\", \"information_requested_incomplete\"}\n}\n\ndeny[msg] {\n sla_breached\n msg := sprintf(\"CMS Prior Authorization Rule violation: %v PA for claim %v has exceeded %v hour/day SLA with status '%v'\", [input.prior_auth_type, input.claim_id, input.elapsed, input.insurance_prior_auth_status])\n}" }, { "pattern_id": "insurance.route_high_severity_claims_to_human_adjuster", "pattern_name": "route_high_severity_claims_to_human_adjuster", "enforcement_effect": "require_hitl_approval", "description": "Block straight-through processing and require human adjuster assignment for claims classified tier_7 (bodily injury) and above. Require compliance officer for regulatory-sensitive claims.", "applicable_enums": [ "ClaimSeverityTier", "StraightThroughProcessingEligibility", "HumanOversightDecision" ], "regulatory_basis": "NAIC Unfair Claims Settlement Practices Act #900; NAIC Model Bulletin consumer harm framework", "rego_sketch": "package insurance.claims.routing\n\nhuman_required_tiers := {\n \"tier_7_casualty_bodily_injury\",\n \"tier_8_litigation_suspected\",\n \"tier_9_fraud_suspected\",\n \"tier_10_regulatory_sensitive\"\n}\n\ndeny[msg] {\n input.insurance_claim_severity_tier in human_required_tiers\n input.insurance_claim_stp_eligibility != \"requires_human_review_before_payment\"\n msg := sprintf(\"NAIC #900 compliance: Claim severity '%v' requires human adjuster assignment — STP blocked\", [input.insurance_claim_severity_tier])\n}\n\ndeny[msg] {\n input.insurance_claim_severity_tier == \"tier_10_regulatory_sensitive\"\n input.gen_ai_hitl_reviewer_role != \"claims_compliance_officer\"\n msg := \"Regulatory-sensitive claim requires claims_compliance_officer HITL review before any payment action\"\n}" }, { "pattern_id": "insurance.naic_ais_program_gate_for_ai_deployment", "pattern_name": "naic_ais_program_gate_for_ai_deployment", "enforcement_effect": "deny", "description": "Block deployment of any new AI system into regulated insurance decision-making in NAIC Model Bulletin adoption states unless the insurer's AIS Program is active and board-approved.", "applicable_enums": [ "NAICAISProgramStatus", "UnderwritingAIModelType", "InsuranceAIModelInventoryStatus" ], "regulatory_basis": "NAIC Model Bulletin (December 2023) — AIS Program required before deploying AI in regulated insurance processes; adopted in 24+ states as of March 2025", "rego_sketch": "package insurance.governance\n\nrequired_program_statuses := {\n \"program_active_board_approved\",\n \"program_under_annual_review\",\n \"program_updated_post_review\"\n}\n\nrequired_inventory_statuses := {\n \"deployed_monitoring_active\",\n \"deployed_high_risk_enhanced_monitoring\"\n}\n\ndeny[msg] {\n not input.insurance_ai_governance_ais_program_status in required_program_statuses\n msg := sprintf(\"NAIC Model Bulletin violation: AIS Program status '%v' does not permit deployment of AI in regulated insurance processes\", [input.insurance_ai_governance_ais_program_status])\n}\n\ndeny[msg] {\n not input.insurance_ai_model_inventory_status in required_inventory_statuses\n msg := \"NAIC Model Bulletin violation: AI model not in approved production inventory status per AIS Program requirements\"\n}" } ] }, "agent_registry_fields": { "description": "Recommended fields for registering an insurance-domain agentic AI system in the GRC portal. These supplement the core agent identity schema from 00_core_sdk_and_governance.json with insurance-specific attributes.", "fields": [ { "field": "naic_company_code", "type": "string", "description": "NAIC Company Code — unique 5-digit identifier assigned to each insurer by the NAIC. Required for state regulatory filings and market conduct examination identification.", "required_when": "All insurance-domain agents" }, { "field": "lines_of_business_in_scope", "type": "array", "enum_ref": "InsuranceLineOfBusiness", "description": "List of insurance lines of business this agent operates in. Determines which state AI regulations apply.", "required_when": "All underwriting, rating, and claims agents" }, { "field": "ais_program_status", "type": "enum", "enum_ref": "NAICAISProgramStatus", "description": "Current status of the insurer's AIS Program per NAIC Model Bulletin requirements.", "required_when": "All agents making or supporting regulated insurance decisions in NAIC Model Bulletin adoption states" }, { "field": "colorado_reg_10_1_1_applicable", "type": "boolean", "description": "True if this agent uses ECDIS in life, auto, or health underwriting in Colorado (effective Oct 15, 2025). Triggers annual bias testing and compliance reporting obligations.", "required_when": "Any agent using external consumer data in Colorado-regulated underwriting" }, { "field": "ecdis_bias_test_status", "type": "enum", "enum_ref": "ECDISBiasTestOutcome", "description": "Current Colorado Reg 10-1-1 / NAIC Model Bulletin bias test outcome for this agent's predictive model." }, { "field": "consumer_facing_decision_type", "type": "string", "description": "Description of the regulated insurance decision this agent makes or supports. Required for NAIC Model Bulletin consumer notice documentation. Example decision types include underwriting acceptance or denial for personal auto, health prior authorisation decisions, and property claim payment authorisation." }, { "field": "stp_eligible", "type": "boolean", "description": "True if this agent is authorised to complete claims or underwriting decisions without human review up to the configured STP threshold.", "required_when": "Claims adjudication and underwriting agents" }, { "field": "california_clinician_review_required", "type": "boolean", "description": "True if this agent processes health insurance decisions in California — requiring licensed clinician review of any adverse determination per California Health & Safety Code §1367.01.", "required_when": "Health, Medicare Advantage, and disability claims agents in California" } ] } }