Member
Navigate care.
What coverage may apply to this care, where can I go, and what cost context is available?
COV / Proposed contract
Care is an event.
Coverage is state.
Who is covered, under which plan, for which benefits, at what time? A proposed contract for the relationships behind the answer.
Starting with self-funded plans
A person has relationships.
A plan has rules.
The member may be a child. The subscriber may be their parent. Employment, benefits, and network access belong to related—but distinct—parts of the model.
Illustrative relationship modelProposed / Not a live lookup
Person AChildMember · Dependent
The person receiving care.
Dependent of
Person BParentSubscriber · Employee
A separate person and role.
Employment
OrganizationEmployerPlan sponsor
Sponsors the self-funded plan.
Coverage connects a member to a plan.Plan + effective period + administrative status
Benefits & accumulators
What the plan describes and what has been used.
Network routes
Where the available evidence directs the workflow.
Administration & payment
Distinct sponsor, administrator, and payer references.
Two clocks. One context.
When did it apply?
When did we learn it?
A late update can change what is known about an earlier period. The draft keeps the effective time and the observation time distinct.
effective_atWhen the requested coverage state is meant to apply.
observed_atWhen the source evidence was observed by the resolver.
evidence_as_ofAn optional draft request field for the evidence cutoff relevant to the question.
A missing, stale, unavailable, or conflicting record must not silently turn into “not covered.”
One state / Different questions
Give each agent
the context it needs.
These are the intended questions shaping the draft. A coverage record alone does not settle every answer.
Provider
Find the payment path.
Which plan and network apply, and where should the claim be routed?
Payer
Prepare a payment review.
Bring coverage context together with encounter, rate, policy, and adjudication evidence.
TPA / Member services
Understand the caller.
Which member record is relevant, how does the person relate to the subscriber, and what appears to be in force?
Supplemental carrier
Identify benefit gaps.
Understand where primary coverage stops and which supplemental benefits may be relevant.
Coverage State reports what administrative evidence indicates was in force. It does not guarantee authorization, medical necessity, participation at the moment of care, an allowed amount, final member responsibility, or payment.
Compose the context
“Was it paid correctly?”
needs more than coverage.
The proposed Coverage State family contributes administrative context. A payment review also needs the documented encounter and the applicable rules.
Encounter LifecycleWhat happened and how it was billed and paid
Coverage StateWhat coverage evidence indicates was in force
Rate, policy & adjudicationThe additional evidence needed for review
Open for design discussion
Inspect the draft.
The draft request uses a subject reference, effective time, and intent. The proposed response relates identities, coverages, benefits, accumulators, network routes, and evidence-backed determinations.
Both schemas may change before activation. They do not represent an executable service.
Help shape the next contract
Bring the coverage question.
We’re interested in the relationships, evidence gaps, and administrative decisions your agents encounter.