EOB — Medicare Advantage. Plan: Health First MA. Member: MEM-39056. Date of Service: 2026-04-02 to 2026-04-09. Provider: Magnolia Skilled Nursing Facility (NPI 0000000007). Service: SNF admission days 1-7. Billed: $2800. Allowed: $0. Paid: $0. CARC 119 — Benefit maximum for this time period or occurrence has been reached. Declined: Member's prior hospital stay was 2 days inpatient + 1 day under observation. Plan applies the three-day inpatient hospital stay rule strictly.
Appeal under 42 CFR §422.626 with two independent grounds: (1) MA plans have discretion to waive the 3-day inpatient rule under value-based care arrangements per CMS guidance; verify whether member is enrolled in such an arrangement. (2) Challenge the observation-status classification — if the patient met inpatient admission criteria but was held under observation status, this is a billable hospital appeal under the 'two-midnight rule.' If the member's case meets either ground, the SNF denial should be reversed. Time-sensitive: file fast-track within hours of receiving notice.
The three-day rule has known waiver pathways in MA — the rigid application here may not be appropriate. Strong appeal grounds when the original observation-status classification is contestable (often is).
Borderline — strict three-day rule denials in MA can sometimes succeed and sometimes fail depending on the specific plan's value-based arrangements. Tests whether the model surfaces the waiver pathway.
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.