Determine eligibility

Trigger: An applicant submits a coverage application or a provider submits a verification inquiry.

1. Receive the enrollment application or verification request.
2. Extract demographic, employment, and qualifying life event data.
3. Validate applicant identity and residency credentials.
4. Query external government or employer databases for coverage prerequisites.
5. Determine qualification for specific health plans or subsidies.
6. Record the eligibility status in the member management system.
7. Transmit the formal eligibility decision to the applicant or provider.

Outcome: The individual's coverage eligibility is definitively established, recorded in the administrative system, and communicated to the requestor.