EOB — Medicare Advantage. Plan: Health First MA. Member: MEM-86034. Date of Service: 2026-04-21. Provider: Coastal Orthopedic Surgery (NPI 0000000010). Service: Office consultation, level 4 (CPT 99244). Billed: $385. Allowed: $0. Paid: $0. CARC 22 — This care may be covered by another payer per coordination of benefits. Diagnosis on file: M67.821 (rotator cuff strain, left shoulder). Member reported the injury occurred at work on 2026-04-15 (warehouse staffing assignment). Workers' Comp claim status: pending acceptance.
Do not appeal the MA plan denial. Workers' Compensation is the legally-required primary payer for occupational injuries — appealing the MA plan would not produce coverage. Coordinate with the member's employer or the WC carrier to confirm claim status. If WC is denied (the injury is not deemed work-related), the provider can resubmit to the MA plan with the WC denial attached and the MA plan will reprocess as primary. Time-sensitive: WC has filing deadlines; member should not delay the WC claim.
WC primary-payer rules are statutory. Until WC accepts or denies, MA plan correctly defers. The right CSR action is shepherding the WC claim, not appealing the MA denial. Strong refuse-to-appeal scenario.
Borderline because once WC is decided, the path forward differs sharply (primary-payer flip if WC denies). Tests whether the model surfaces the conditional reprocessing path.
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.