EOB — Medicare Advantage. Plan: Health First MA. Member: MEM-58904. Date of Service: 2026-04-10. Provider: Cocoa Beach Hospital (NPI 0000000006). Service: Outpatient laboratory panel (CPT 80053). Billed: $185. Allowed: $0. Paid: $0. CARC 18 — Exact duplicate claim/service. Referenced original claim 26-0414-7822 was processed on 2026-04-14 and DENIED for missing documentation. The claim under review (26-0418-3491) is a resubmission with the same service codes. Original denial appeal/correction status unclear from the EOB face.
No appeal of the duplicate denial is appropriate. The triage path is: (1) ask the member or provider for the status of the original claim (claim 26-0414-7822) — was the missing documentation submitted? Was that claim corrected and reprocessed? (2) If the original is now paid or pending payment, this resubmission is correctly flagged as duplicate. (3) If the original is still denied, the appeal pathway is on the original claim's documentation gap, not on this duplicate flag. Request itemized claim history to clarify.
The interesting nuance here is that the 'original' claim was itself denied for documentation. The duplicate flag is still correct — you can't appeal a duplicate just because the underlying claim has issues. The appeal needs to be on the original, not the resubmission. The CSR triage requires investigation to surface this.
Borderline — duplicate flag is correct procedurally but underlying coverage may still be at issue. Tests whether the model recommends investigating the original claim rather than reflexively recommending appeal of the duplicate.
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.