EOB — Medicare Advantage Working Aged. Plan: Health First MA. Member: MEM-25441. Date of Service: 2026-04-12. Provider: Sunrise Family Medicine (NPI 0000000002). Service: Annual physical (CPT 99396). Billed: $245. Allowed: $0. Paid: $0. CARC 22 — This care may be covered by another payer per coordination of benefits. Member's coverage records show active employer-group plan (Group 4521-A). Member is age 67 and currently working full-time. Per Medicare Secondary Payer rules, the employer plan is primary; this MA plan is secondary.
No appeal of this MA plan's denial is appropriate. Direct the provider to bill the employer-group plan (Group 4521-A) first. Once that plan adjudicates and issues an EOB, the provider can submit this claim to the MA plan as secondary with the primary EOB attached. Member should not pay anything out of pocket beyond what their employer plan determines as their cost-share.
Working-aged Medicare Secondary Payer rules are explicit: employer plan is primary for actively working members aged 65+. The MA plan's denial is procedurally correct. Filing an appeal would be inappropriate and would not change the MSP determination. Right triage: refuse to appeal, redirect to billing flow.
Per-scenario model output is captured during a leaderboard Run all. Trigger a run from the leaderboard to see each variant’s output side-by-side with the ground truth here.
To run this scenario through the live cockpit, copy the EOB above into the cockpit and watch the streamed triage in context.