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Setting up claim submission

Updated on January 18, 2022
Case management supports the entire life cycle of a claim including prior approvals, claim entry, pre- validation and validation, auto adjudication, manual review, settlement, and appeals. A warranty claim is a set of cases and subcases that are managed independently while allowing the entire case structure view. Validation of the claim occurs at two points in the claims process:
  • Pre-validation,when rules are executed before the claim is submitted to the adjudication system.
  • Validation,which occurs during the claim adjudication, after the claim has been submitted to the manufacturer.
Pre-validation rules

Pega Warranty has a number of pre-configured rules that implement a sample set of business rules:

  • PreValidationForPart, where a certain part number requires an invoice number.
  • PreValidationForMisc,where miscellaneous expense codes require an invoice attached to the claim.
  • PreValidationForLabor,where labor hours cannot exceed the defined amount for a particular labor activity.
  • ProductCheckInDate, where a date cannot be set in the future.
  • OdometerReading,where the odometer reading cannot be less than the last reading on record for the vehicle.
  • CoverageExists,where the claim cannot be entered if there is no valid coverage available. When these conditions are not met for any line, a warning icon appears.

The ClaimValidation subflow handles all the validations related to the claim in the validate claim step.

When a claim passes through this flow, all the exceptions related to the claim are flagged and added to the claim. This subflow also determines the claim disposition as paid, denied, or manually assessed.

To review the ClaimsValidation flow steps, enter ClaimsValidation in the Dev Studio header search text field and click it to open.

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