Eligibility · Deterministic · Governed · Auditable

Eligibility Decisions That Are Consistent — and Defensible.

Whether it’s benefits, coverage, or program access, eligibility rules live in statute and policy that no system executes the same way twice. Compile them into governed decision packages: deterministic determinations, structured evidence requests, and a signed trace for every appeal.

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Zero AI at runtime. Deterministic. Auditable. Traceable.

The problem

The same rules, different answers

Eligibility criteria are interpreted differently by whoever reviews the case, so identical applicants receive different outcomes — and denials get overturned on appeal. Determinations should be deterministic and auditable, not reviewer-dependent.

Criteria trapped in policy manuals

Income tests, categorical rules, and coverage criteria live in regulations and manuals that no system can execute consistently. Sertainly compiles them into versioned, governed decision packages with citations to the governing clause.

No way to reproduce a past determination

When rules change, proving which criteria applied to a decision made last year is manual archaeology. Every determination should replay against the rules in force on its own effective date.

How Sertainly Helps

Deterministic criteria evaluation

Eligibility rules — income and asset tests, categorical and composition rules — compiled into decision packages that return the same result every time.

  • Income and asset threshold tests against program limits
  • Categorical eligibility and household-composition rules
  • Multi-program rule sets evaluated in one pass
  • Identical result across offices, channels, and systems

Structured evidence handling

When documentation is missing, the package returns a structured evidence request instead of a guess — and re-evaluates deterministically once evidence arrives.

  • Structured evidence request when verification is missing
  • Document-sufficiency checks against program requirements
  • Blocking vs. non-blocking evidence distinctions
  • Clean re-evaluation on receipt of the missing evidence

Defensible & reproducible

Every determination carries a signed trace and replays against the exact rules in force on its date — so a decision made last year is reproducible today.

  • Signed trace with clause citations for fair-hearing appeals
  • Reproduce any determination against the rules in force on its date
  • Reason codes tied to the governing statute or regulation
  • Immutable audit trail for oversight and review

Coverage eligibility: Medicaid determination

An application is submitted for evaluation. Sertainly runs the income and residency tests for the program and returns a deterministic determination with full trace.

evaluate_case input

{
  "version": 2,
  "case": {
    "household": {
      "size": 3,
      "annual_income": 28000
    },
    "applicant": {
      "program": "MEDICAID",
      "state": "CO",
      "age": 34
    }
  }
}

evaluate_case output

{
  "status": "ok",
  "outputs": {
    "tags": ["ELIGIBLE"],
    "reason_codes": [
      "INCOME_UNDER_138_FPL",
      "RESIDENCY_CONFIRMED"
    ],
    "facts": {
      "fpl_percent": 108
    }
  },
  "trace_id": "tr_elig_5a1c…"
}

Applies across

The same decision layer, wherever this problem shows up.

Government →Healthcare →Insurance →

Sertainly doesn't replace your existing platforms — it supplies the governed, traceable decision packages they call.

Ready for eligibility decisions you can defend on appeal?

Compile policy into governed decision packages. Execute deterministically with full trace, provenance, and audit controls. Same decision layer across every industry.

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