Auto-Claim Lifecycle, Subcases, and Reopened Payments
TransContoso Insurance receives 2,300 auto claims per day across 12 regions. The current Pega case type has stages Intake, Triage, Investigation, Decision, and Payment. Medical review and fraud check are modeled as subcases. The initial-contact SLA is 4 business hours; the decision SLA is 10 business days. Adjusters report three symptoms: duplicate medical-review subcases appear for the same claim, assignments sit in shared worklists because skill-based routing uses skills that were never mapped to operators, and a claim reopened after payment restarts at Intake and can trigger a second payment. The send-acknowledgment process currently fires whenever the claim enters Investigation as well as Intake. Regional managers also want a withdrawn path that preserves the claim record but stops all SLAs. The team has one month before a pilot in two regions.
1. Decide which work should be a subcase, which should be a process in a stage, and which should be case-wide. Use the claim symptoms to justify.
Read the worked answer
Medical review and fraud check should remain subcases because they have independent owners, can run in parallel, and need their own deadlines and reporting. The duplicate subcases are not a reason to remove them; they are a missing guard. Add a check before creating a child case, such as verifying an existing open medical-review child for the claim, and make the create step idempotent.
Send acknowledgment belongs in the Intake stage as a stage-level process, because it is stage-specific and should not run on Investigation entry. A case-wide process is appropriate only for work that must be available from any stage, such as recording a payment correction. Withdrawal should be an alternate stage that stops SLAs and preserves the record. This separation keeps ownership, timing, and reuse understandable.
2. Explain how to model reopening a paid claim so a second payment is impossible, including status, stage, and data handling.
Read the worked answer
Do not reopen by sending the case back to Intake. Intake represents initial capture and will re-run validation and assignment logic that no longer applies. Instead, model a post-payment review path, either as an alternate stage reachable from the resolved-payment status or as a separate review case linked to the original.
If the original claim is reopened, preserve the payment record and use a when condition to block a new payment while a settled payment exists. Require a payment reversal or adjustment before any new disbursement. Set the stage to Post-Payment Review with its own SLA and audit trail. If the customer reports a genuinely new loss, create a new claim and link it as a related case rather than reopening the old one. This prevents duplicate payment and keeps financial history intact.
3. How would you configure SLAs for initial contact and decision when the claim waits on a medical-review subcase?
Read the worked answer
Put the 4-business-hour initial-contact SLA on the Intake stage, because it measures the first customer contact and should start when the claim enters Intake. Put the 10-business-day decision SLA at the level that represents the insurer's overall decision obligation, typically a case-level or Decision-stage SLA, not on individual assignments.
Give the medical-review subcase its own SLA so its owner is measured separately. If the parent decision SLA should pause while the parent waits on the subcase, model that explicitly with the business and test it; do not assume a subcase automatically pauses the parent. Use urgency and reporting to show claims at risk. Test the design with a delayed medical review to confirm the initial-contact timer is unaffected and the decision timer behaves as agreed.