Pega University Program

Pega’s University Program

HealthCare Insurance
(Use Case)

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Copyright 2020
Pegasystems Inc., Cambridge, MA
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Document Name: 33_HealthcareInsurance_UseCase.docx

Date: 26.11.2020

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Table of Contents

Contents
1 HealthCare Insurance – 12hrs ................................................................................................................................... 4

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1 HealthCare Insurance - 12 Hours

Use Case ID UC-33 Version 2.0
Use case Name HealthCare Insurance
Platform Details Pega 8.4 Time for completion 12 Hours
Created By Pradeep Kumar P Last Updated By Sarada Satapathy
Date Created 29.05.2020 Last Revision Date 26.11.2020
Concepts covered 1. Case Management
2. Data Modelling
3. Multi-Step Form
4. Data types
5. Data Pages
6. Reports
7. Correspondence
8. Service Level Agreement
9. Work Parties
Description 1.Insurance for different Age groups (1-15, 16-30, 31-45, 46-60, >60)
2.Age factor to be determined with proof
3.Insurance amount to be applicable according to Plan type and Age
4.Hospital list to be aligned which can provide insurance
5. Medication category to be mentioned like OutPatient, RegularCheckup, Surgery etc.
6. Insurance provision confined to Bills, Doctor treatment etc.
7.Insurance provision to be checked with Reimbursement or Cashless facility
8.Manager has to check with the Insured details –Address Proof, Id Proof etc
9.Insured photo, sign should be proofed to be approved
Actors Applicant, Manager, Insurer
Mock up screens
Case Type: Insurance

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Step: Collect Personal Details

Step: Collect Applicant ID Proofs

Step: Collect Additional Information

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Step : Collect Address Details

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Step: Get Coverage

Step: Add members as Insured

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Step: Select Insurance for Members

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Step: Review Claim Details

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Step: Capture Insured Photo And Signature

Step: Review Application

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Report: Health Report of Insured Member

Trigger New Applicant has to register for HealthCare Insurance

Preconditions N/A
Post conditions 1. Documents like SSN, Licence number, Pan Card must be collected from the
Applicant before registration.
2. Work parties has to be created, after the Applicant register.
Normal Flow 1. Collect Applicant Personal Details such as First Name, Middle Name, Last Name,
Email, Phone Number SSN Number and Address (Temporary and Permanent).
2. Collect Additional Information such as Applicant Martial Status, Annual income.
3. Collect Address Details like Temporary Address and Permanent Address
4. Get coverage details and to whom the health coverage by adding members.

5. Select insurance type based on the Health care plans available for the added
members. This step displays the Premium amount which has to be paid by applicant.
Premium Amount is calculated based on Plan for Years, Age and Insured Amount.
6. Finally review the details entered by user and also capture Photo and Signature
7. Once the application is submitted, it has to route to the manager of the HealthCare
Insurance Company for approval. Manager must approve the application with in 48
Hrs.
8. Once manager approves it, mail has to be send to applicant regarding confirmation.
Alternate Flows N/A
Exceptions In Registration process Healthcare Insurance Manager may reject the application if applicant
provides incorrect information during registration.
Rejected email is sent to applicant with reason mentioned.
Includes N/A
Frequency of Use N/A
Special 1. On portal, Health Insurance company logo should be configured.
Requirements 2. Once Applicant agrees the Terms and Condition “Continue” button should be
enabled
3. If Applicant accepts the terms and conditions then continue button should enable
4. Apply validations on the respective properties. To validate Social Security Number
use OOTB “SSN” validation rule.
5. Create Page Group Properties for Temporary Address and Permanent Address
6. Registered applicant information has to be stored in the local data source. (Applicant
Personal details).
7. Create “Paragraph” Rule to Display images and content on the screen.
8. “Upload Image” in Applicant.
9. “Signature Control” in Application
10. “Tab Layout” is used to display Insured members, applicant has to select specific
HealthCare Plan for that person

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11. Manager of the HealthCare Insurance Company, wants report that tracks the all
Insured details based on Insurance type.
12. Manager also wants to see the Health report of the Insured members (Note: This
report tell how health Insured member is.)

Enhancements:

a. Country name should be extracted using Connect REST. Use the following url
https://restcountries.com/?msclkid=b5e7a289c1fc11ecaabd39b034364d94

b. After Insurance is purchased, a PDF document should be generated with all the
details of Policy including members, premium details, benefits.
c. Send the generated Policy document through email
d. Use work parties for Applicant, Insurance manager.
e. If the Insurance manager doesn’t approve within given timeline, (4 to 6 days max),
request should send to Regional Manager for approval by sending proper
notifications to the Customer and manager.
Future 1. In the next version of the application, will check for the duplication of the Applicants
Requirements
Assumptions N/A
Notes and Issues N/A
Acceptance Criteria 1. Once Applicant selects Medical Category type from list, it should be copied to
(scenarios for Unit selected insurance property.
Testing) 2. Email body must contain all details of the HealthCare insurance

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