# Faultprint Structural Assessment: UnitedHealthcare AI and Prior Authorization

## Assessment Boundary

This assessment identifies document-visible structural conditions. It does not assert institutional failure, illegality, misconduct, causation, or future outcomes.

## Corpus Position

|field|value|
|---|---|
|Institution|UnitedHealthcare AI and Prior Authorization|
|Sector|Health insurance|
|Corpus reviewed|Public source materials represented in the current operating library.|
|Assessment scope|Selected source-anchored operating rows for example assessment formatting.|

## Module Screen

|module|screen result|reason|
|---|---|---|
|Contestability Lag|visible condition|Appeals and grievances tracking requirements visible|
|AI Authority Acceleration|not visible in selected rows|No source-anchored finding selected for this module.|
|Record-Authority Capture|not visible in selected rows|No source-anchored finding selected for this module.|
|Access Interruption Before Review|not visible in selected rows|No source-anchored finding selected for this module.|
|Documentation Burden Transfer|not visible in selected rows|No source-anchored finding selected for this module.|
|Classification Gatekeeping|visible condition|Claims Assistant supports out-of-network claim submission|
|Evidence-Container Illusion|not screened as standard module|Pilot module; use only with strong source support.|
|Multi-Actor Handoff Diffusion|not screened as standard module|Pilot module; use only with strong source support.|
|Deadline Compression|not screened as standard module|Pilot module; use only with strong source support.|

## Findings

### FP-F-001: Prior authorization and coverage determinations are consequential pathways

|field|content|
|---|---|
|Module|Contestability Lag|
|Condition name|Prior authorization and coverage determinations are consequential pathways|
|Source anchor|The page describes coverage determinations prior authorization denials appeals and timing rules.|
|Source location|https://www.uhc.com/medicare/resources/prescription-drug-appeals.html|
|Why it matters structurally|Operating row shows a condition also present in postmortem libraries, but current public evidence is not enough to treat it as high exposure.|
|Boundary|Does not establish wrongful denial.|
|Falsification evidence|Denial and appeal records showing low error and fast correction would downgrade exposure.|

### FP-F-002: Different reviewers are described for appeals

|field|content|
|---|---|
|Module|Contestability Lag|
|Condition name|Different reviewers are described for appeals|
|Source anchor|The page describes appeal review by people who were not involved in the original decision.|
|Source location|https://www.uhc.com/medicare/resources/prescription-drug-appeals.html|
|Why it matters structurally|Operating row is visible as an operating condition but has limited postmortem resemblance in this pass.|
|Boundary|Does not prove appeals are substantively effective.|
|Falsification evidence|Appeal records showing same-decision rubber-stamping would weaken this mitigant.|

### FP-F-003: Appeals and grievances tracking requirements visible

|field|content|
|---|---|
|Module|Contestability Lag|
|Condition name|Appeals and grievances tracking requirements visible|
|Source anchor|The page states health plans must follow strict rules to identify track resolve and report appeals and grievances.|
|Source location|https://www.uhc.com/communityplan/learn-about-medicare/appeals-grievances-process|
|Why it matters structurally|Operating row is visible as an operating condition but has limited postmortem resemblance in this pass.|
|Boundary|Does not prove compliance quality.|
|Falsification evidence|Audit findings showing tracking or resolution failures would weaken this mitigant.|

### FP-F-004: Public no-AI-adverse-claims-decision statement

|field|content|
|---|---|
|Module|Classification Gatekeeping|
|Condition name|Public no-AI-adverse-claims-decision statement|
|Source anchor|UHC states it does not use and has never used AI to make adverse decisions related to claims.|
|Source location|https://www.uhc.com/agents-brokers/employer-sponsored-plans/news-strategies/ai-for-better-care-faq|
|Why it matters structurally|Operating row shows a condition also present in postmortem libraries, but current public evidence is not enough to treat it as high exposure.|
|Boundary|Does not establish that UHC AI tools caused improper denials or failed appeals in any reviewed case.|
|Falsification evidence|Contrary model inventory denial logs or operational records would weaken this mitigant.|

### FP-F-005: Claims Assistant supports out-of-network claim submission

|field|content|
|---|---|
|Module|Classification Gatekeeping|
|Condition name|Claims Assistant supports out-of-network claim submission|
|Source anchor|UHC describes Claims Assistant AI as supporting out-of-network claim submissions by simplifying forms.|
|Source location|https://www.uhc.com/news-articles/newsroom/consumer-innovation|
|Why it matters structurally|Operating row shows a condition also present in postmortem libraries, but current public evidence is not enough to treat it as high exposure.|
|Boundary|Does not prove AI makes claims decisions.|
|Falsification evidence|Product records showing no downstream claim decision effect would downgrade exposure.|

## Evidence Ledger

|evidence id|document/source|anchor|supports finding|
|---|---|---|---|
|E-001|https://www.uhc.com/medicare/resources/prescription-drug-appeals.html|The page describes coverage determinations prior authorization denials appeals and timing rules.|FP-F-001|
|E-002|https://www.uhc.com/medicare/resources/prescription-drug-appeals.html|The page describes appeal review by people who were not involved in the original decision.|FP-F-002|
|E-003|https://www.uhc.com/communityplan/learn-about-medicare/appeals-grievances-process|The page states health plans must follow strict rules to identify track resolve and report appeals and grievances.|FP-F-003|
|E-004|https://www.uhc.com/agents-brokers/employer-sponsored-plans/news-strategies/ai-for-better-care-faq|UHC states it does not use and has never used AI to make adverse decisions related to claims.|FP-F-004|
|E-005|https://www.uhc.com/news-articles/newsroom/consumer-innovation|UHC describes Claims Assistant AI as supporting out-of-network claim submissions by simplifying forms.|FP-F-005|

## Counter-Signals

|counter-signal|source location|effect on finding|
|---|---|---|
|The page describes appeal review by people who were not involved in the original decision.|https://www.uhc.com/medicare/resources/prescription-drug-appeals.html|May narrow or weaken the condition if confirmed by operating records.|

## Falsification Checklist

|finding|records that would weaken or rebut the finding|
|---|---|
|FP-F-001|Denial and appeal records showing low error and fast correction would downgrade exposure.|
|FP-F-002|Appeal records showing same-decision rubber-stamping would weaken this mitigant.|
|FP-F-003|Audit findings showing tracking or resolution failures would weaken this mitigant.|
|FP-F-004|Contrary model inventory denial logs or operational records would weaken this mitigant.|
|FP-F-005|Product records showing no downstream claim decision effect would downgrade exposure.|

## Non-Claims

- This assessment does not recommend institutional action.
- This assessment does not predict failure.
- This assessment does not assert illegality.
- This assessment does not score the institution against a public benchmark.