CN107909487A - Claims Resolution method, apparatus and system based on medical insurance - Google Patents
Claims Resolution method, apparatus and system based on medical insurance Download PDFInfo
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- CN107909487A CN107909487A CN201711110993.8A CN201711110993A CN107909487A CN 107909487 A CN107909487 A CN 107909487A CN 201711110993 A CN201711110993 A CN 201711110993A CN 107909487 A CN107909487 A CN 107909487A
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Abstract
This application discloses a kind of Claims Resolution method, apparatus and system based on medical insurance, it is related to settlement of insurance claim technical field, the Claims Resolution efficiency of medical insurance can be improved.The described method includes：When insurance company server receives the Claims Resolution request that hospital side's client is sent, the medical bills information of the user to be settled a claim carried in the Claims Resolution request is obtained；And the policy information of user to be settled a claim described in inquiry；According to the policy information and the medical bills information, whether user to be settled a claim described in detection meets predetermined straight knot condition；If, then the bill in the medical bills information is detailed, with corresponding Claims Resolution limit detailed with the bill and Claims Resolution ratio in the policy information, the corresponding amount for which loss settled of the user to be settled a claim is determined, and corresponding straight knot Claims Resolution operation is carried out according to the amount for which loss settled.The application is suitable for the Claims Resolution of medical insurance.
Description
Technical field
This application involves settlement of insurance claim technical field, more particularly to a kind of Claims Resolution method, apparatus based on medical insurance
And system.
Background technology
With the development of society, medical insurance is more and more important to people.Medical insurance is for caused by compensation disease
A kind of insurance of medical expense, when worker is because of disease, injured, fertility, necessary medical services or thing are provided by society or enterprise
The social insurance that matter helps.
At present for having bought the user of medical insurance, when the user removes hospital admission, it is necessary to first pay hospital's phase
The cost of medical service of pass, then could go to a doctor and see a doctor, the subsequent expense bill paid the fees returned by hospital go insurance company into
Row Claims Resolution.
However, the Claims Resolution mode of above-mentioned this medical insurance is comparatively laborious for a user, it is necessary to which user goes insurance public
Department carries out Claims Resolution clearing, can expend user's excessive time, and then can influence the Claims Resolution efficiency of medical insurance, so as to have impact on use
The experience at family.
The content of the invention
In view of this, this application provides a kind of Claims Resolution method, apparatus based on medical insurance and system, main purpose to exist
It is comparatively laborious for a user in the Claims Resolution mode for solving medical insurance traditional at present, user's excessive time can be expended,
And then the Claims Resolution efficiency of medical insurance can be influenced, so that the problem of have impact on the experience of user.
According to the application on one side, there is provided a kind of Claims Resolution method based on medical insurance, this method include：
When insurance company server receives the Claims Resolution request that hospital side's client is sent, obtain in the Claims Resolution request
The medical bills information of the user to be settled a claim carried；And
The policy information of user to be settled a claim described in inquiry；
According to the policy information and the medical bills information, whether user to be settled a claim described in detection meets predetermined straight knot
Condition；
If so, then bill in the medical bills information is detailed, and in the policy information it is bright with the bill
Thin corresponding Claims Resolution limit and Claims Resolution ratio, determine the corresponding amount for which loss settled of the user to be settled a claim, and according to the Claims Resolution gold
Volume carries out corresponding straight knot Claims Resolution operation.
According to the application on the other hand, there is provided a kind of Claims Resolution device based on medical insurance, the device include：
Acquiring unit, for when insurance company server receives the Claims Resolution request that hospital side's client is sent, obtaining
The medical bills information of the user to be settled a claim carried in the Claims Resolution request；
Query unit, for inquiring about the policy information of the user to be settled a claim；
Detection unit, the medical treatment that policy information and the query unit for being obtained according to the acquiring unit inquire
Whether bill information, user to be settled a claim described in detection meet predetermined straight knot condition；
Claims Resolution unit, if detecting that the user to be settled a claim meets predetermined straight knot condition for detection unit, according to institute
The bill stated in medical bills information is detailed, and corresponding Claims Resolution limit detailed with the bill and Claims Resolution in the policy information
Ratio, determines the corresponding amount for which loss settled of the user to be settled a claim, and carries out corresponding straight knot Claims Resolution behaviour according to the amount for which loss settled
Make.
According to the application another aspect, there is provided a kind of Claims Resolution system based on medical insurance, including insurance company's clothes
Business device and hospital side's client；
Hospital side's client, for obtaining the medical bills information of user；According in the medical bills information
Whether user identifier, inquire about the user insured medical insurance；If so, the user is then determined as user to be settled a claim,
And the Claims Resolution request for carrying user's medical bills information to be settled a claim is sent to the insurance company server；
The insurance company server, in the policy information of user to be settled a claim according to and medical bills letter
Breath, determine it is described after Claims Resolution user meets predetermined straight knot condition, according to the corresponding amount for which loss settled progress of user settle a claim
Corresponding straight knot Claims Resolution operation.
According to the application another aspect, there is provided a kind of storage device, is stored thereon with computer program, described program
The above-mentioned Claims Resolution method based on medical insurance is realized when being executed by processor.
According to the application another aspect, there is provided a kind of entity apparatus based on medical insurance Claims Resolution, including storage are set
Standby, processor and storage on a storage device and the computer program that can run on a processor, described in the processor execution
The above-mentioned Claims Resolution method based on medical insurance is realized during program.
By above-mentioned technical proposal, a kind of Claims Resolution method, apparatus and system based on medical insurance that the application provides, with
The Claims Resolution mode of traditional medical insurance is compared at present, and the application can be by hospital side's client by the medical account of user to be settled a claim
Single information is sent to insurance company server so that insurance company server is in the policy information according to the user to be settled a claim and doctor
Bill information is treated, determines this after Claims Resolution user meets predetermined straight knot condition, directly according to the corresponding Claims Resolution gold of user to be settled a claim
Volume carries out corresponding straight knot Claims Resolution operation, carries out Claims Resolution accounting without user Zai Qu insurance companies to be settled a claim, saves insurance reason
Settlement time is paid for, the Claims Resolution efficiency of medical insurance is improved, enhances the experience of user.
Described above is only the general introduction of technical scheme, in order to better understand the technological means of the application,
And can be practiced according to the content of specification, and in order to allow above and other objects, features and advantages of the application can
Become apparent, below especially exemplified by the embodiment of the application.
Brief description of the drawings
By reading the detailed description of hereafter preferred embodiment, it is various other the advantages of and benefit it is common for this area
Technical staff will be clear understanding.Attached drawing is only used for showing the purpose of preferred embodiment, and is not considered as to the application
Limitation.And in whole attached drawing, identical component is denoted by the same reference numerals.In the accompanying drawings：
Fig. 1 shows a kind of Claims Resolution method flow schematic diagram based on medical insurance provided by the embodiments of the present application；
Fig. 2 shows a kind of structure diagram of Claims Resolution device based on medical insurance provided by the embodiments of the present application；
Fig. 3 shows the structure diagram of another Claims Resolution device based on medical insurance provided by the embodiments of the present application；
Fig. 4 shows another Claims Resolution system structure diagram based on medical insurance provided by the embodiments of the present application.
Embodiment
The exemplary embodiment of the disclosure is more fully described below with reference to accompanying drawings.Although the disclosure is shown in attached drawing
Exemplary embodiment, it being understood, however, that may be realized in various forms the disclosure without should be by embodiments set forth here
Limited.On the contrary, these embodiments are provided to facilitate a more thoroughly understanding of the present invention, and can be by the scope of the present disclosure
Completely it is communicated to those skilled in the art.
The embodiment of the present application provides a kind of Claims Resolution method based on medical insurance, can be applied to insurance company side, real
The Claims Resolution efficiency of medical insurance is now improved, as shown in Figure 1, this method includes：
101st, when insurance company server receives the Claims Resolution request that hospital side's client is sent, obtain in Claims Resolution request
The medical bills information of the user to be settled a claim carried, and inquire about the policy information of user to be settled a claim.
Wherein, in medical bills information comprising user to be settled a claim userspersonal information (such as the age, gender, identification card number,
Work unit etc.), need pay general expenses information (such as expense title, Fee Amount), user settle a claim treatment place
The content such as medical institutions' information (such as medical institutions' code, hospital or practice name).Identified in policy information comprising declaration form
Information (such as declaration form numbering, title), declaration form insurance kind information, policy type information (such as personal insurance, group insurance), declaration form are insured
Amount information, declaration form responsibility managing detailed catalogue (Claims Resolution ratio, Claims Resolution scope, Claims Resolution limit, the Claims Resolution condition of such as general expenses)
Etc. content.
In the embodiment of the present application, on the premise of user confirms straight knot Claims Resolution, the medical treatment of the user is generated in hospital side
After bill information, hospital side's client can be sent to, hospital side's client when judging the user's insured medical insurance,
User to be settled a claim is determined that the user is, and inquires about the mailing address of the insured insurance company of user to be settled a claim, such as insurance company
Universal resource locator (Uniform Resource Locator, URL) address of square related medical settlement of insurance claim processing website,
Internet protocol address (Internet Protocol Address, IP) of server etc., after the mailing address is inquired,
The Claims Resolution request of the user to be settled a claim can be sent to insurance company server corresponding with the mailing address.And for the application
The executive agent of embodiment can be fast to settle a claim the server or device of business for handling medical insurance, be used for realization basis
The policy information and medical bills information of user to be settled a claim carries out the rapid safety Claims Resolution clearing of user to be settled a claim.
102nd, according to the policy information inquired and the medical bills information got, detect whether user to be settled a claim meets
Predetermined straight knot condition.
Wherein, making a reservation for straight knot condition can be set in advance according to the actual requirements.For example, the guarantor according to user to be settled a claim
Whether single information, inquiry the user buy medical insurance product, and whether which is the insurance for supporting straight knot service
Product, whether the user is straight knot Claims Resolution black list user, and whether the number for needing to settle a claim exceedes the maximum of the insurance products
Claims Resolution limit, and whether the medical institutions that the user treats are in the range of it can directly tie Claims Resolution medical institutions；If the user purchases
Bought medical insurance product and the medical insurance product support service of directly tying and the user be not straight knot Claims Resolution black list user,
And the number for needing to settle a claim is not above the maximum Claims Resolution limit of the medical insurance product, then illustrate that the user meets predetermined straight knot
Condition.
If the 103, user to be settled a claim meets predetermined straight knot condition, the bill in the medical bills information got is bright
Carefully, detailed with bill corresponding Claims Resolution limit and Claims Resolution ratio and in the policy information that inquires, determine user's correspondence settle a claim
Amount for which loss settled, and carry out corresponding straight knot Claims Resolution operation according to amount for which loss settled.
For example, in the medical bills information of user to be settled a claim comprising hospitalization and medical treatment expenses, be in hospital bed take, hospitalisation for surgery expense,
Inquire about to the responsibility detail of this three expenses in the medical declaration form of the user, the Claims Resolution ratio and Claims Resolution for finding this three expenses limit
Volume, finally calculates the corresponding amount for which loss settled of the user, and according to the amount for which loss settled, by the medical insurance settling fee of the user
Throw hospital's account into, operation is directly tied to complete the Claims Resolution of the user's medical bills information, if settling fee is taken less than bill
With then the user needs polishing difference, and then realizes medical bills payment of fees.
A kind of Claims Resolution method based on medical insurance provided by the embodiments of the present application, the Claims Resolution side with traditional medical insurance
Formula is compared, the embodiment of the present application need not user Zai Qu insurance companies be settled a claim carry out Claims Resolution accounting, save settlement of insurance claim clearing
Time, improves the Claims Resolution efficiency of medical insurance, it is relevant to hospital that such user may not need payment or partial payment in advance
Medical expense, it is possible to realize to go to a doctor and see a doctor, greatly enhance the experience of user.
Further, the refinement and extension as above-described embodiment embodiment, in order to illustrate the specific of step 102
Implementation process, in the alternative embodiment of the application, step 102 can specifically include：According to the policy information inquired,
Inquire about the medical insurance product information of user to be settled a claim purchase, and detect the medical insurance product information inquired whether support it is pre-
Put straight knot service；And/or bill in the medical bills information got is detailed, and in the policy information inquired with account
Whether single detailed corresponding Claims Resolution limit and Claims Resolution ratio, the amount of money that detection needs to settle a claim are more than the most Dali of insurance product information
Pay for limit；And/or detect whether user to be settled a claim is preset straight knot Claims Resolution black list user；And/or detect user to be settled a claim and exist
Whether the settlement of insurance claim number in predetermined amount of time is more than predetermined times threshold value.
When medical insurance product information supports preset straight knot service, and/or the amount of money for needing to settle a claim to be less than or equal to insurance
The maximum Claims Resolution limit of product information, and/or user to be settled a claim are not preset straight knot Claims Resolution black list user, and/or insurance reason
Pay for number and be less than predetermined times threshold value, determine that user to be settled a claim meets predetermined straight knot condition.
For example, insurance company's square gauge only has a few high-end medical insurance product just to support preset straight knot service surely, insurance is public
Take charge of server to be numbered according to the declaration form of user's declaration form to be settled a claim, whether the medical insurance product that can inquire about the user's purchase belongs to
One kind in this few high-end medical insurance product, on the premise of the preset straight knot service of the medical insurance product support, ability
Follow-up straight knot Claims Resolution operation is carried out, insurance company may further specify that some securities are higher, the less medical treatment of complexity is protected
Preset straight knot service of dangerous product support etc., specifically can be depending on the business demand of insurance company；Insurance company server is also
Can be detailed according to the bill in medical bills information, and corresponding Claims Resolution limit detailed with the bill and Claims Resolution in policy information
Ratio, calculates how much each bill expense needs compensation, is finally added and obtains needing the total amount settled a claim, judges that the total amount is
The maximum Claims Resolution limit of the no medical insurance product more than the user's purchase, is less than or equal to maximum Claims Resolution limit in the total amount
During volume, follow-up straight knot Claims Resolution operation could be carried out, the maximum Claims Resolution limit of each medical insurance product can be according in declaration form
Appearance is set.
For another example in order to ensure the security of directly knot Claims Resolution operation, the straight knot Claims Resolution risk of insurance company is reduced, can be pre-
Some first are existed user information recording in violation of rules and regulations, before there are behaviors such as insurance frauds to be stored in straight knot Claims Resolution blacklist,
Detect when whether the user that settles a claim meets predetermined straight knot condition, it can be determined that whether the user is straight knot Claims Resolution black list user,
If black list user, illustrating to carry out the user directly knot Claims Resolution operation can be there are great risk, and then determines the user not
Meet predetermined straight knot condition；If not black list user, but the user exists more multiple in the time of nearest two weeks
Settlement of insurance claim operation, can specifically include straight knot Claims Resolution operation and/or the Claims Resolution operation of other general insurances etc., illustrate the user
Settlement of insurance claim is often carried out recently, it may be possible to insurance fraud user, in order to ensure the security of directly knot Claims Resolution operation, it may be determined that the use
Family does not meet predetermined straight knot condition.
, can be with it should be noted that in addition to the specific implementation process for the step 102 that above-mentioned alternative embodiment provides
With reference to factors such as the declaration form insurance kind of user to be settled a claim, policy type, declaration form insured amounts, it is pre- whether comprehensive distinguishing the user meets
Fixed straight knot condition, can specifically be set according to the business demand of insurance company.
In order to further ensure the security of straight knot Claims Resolution operation, in the alternative embodiment of the application, step 102
It can also specifically include：Obtain the credit evaluation information of user to be settled a claim；According to the credit evaluation information of acquisition, detect and wait to settle a claim
Whether the credit scoring of user is greater than or equal to predetermined scoring threshold value, and/or the user to be settled a claim credit evaluation grade whether
More than or equal to predetermined grade threshold；When the credit scoring of the user is small less than predetermined scoring threshold value, and/or credit evaluation grade
When predetermined grade threshold, determine that user to be settled a claim does not meet predetermined straight knot condition.Wherein, scoring threshold value and predetermined grade are made a reservation for
Threshold value can be set according to the safe class situation of business reality.
It is public for the user to be settled a claim that some credits are in bad order, credit rating is poor, insurance in this alternative embodiment
Department performs it straight knot Claims Resolution operation of insurance, can be there are certain risk, thus may determine that the user does not meet predetermined straight knot
Condition.
Further, in order to acquire, more accurately, more comprehensively user credit to be settled a claim assesses information, above-mentioned to obtain
The step of credit evaluation information for taking user to be settled a claim, can specifically include：By inquiring about external system, user to be settled a claim is obtained
Credit evaluation information, believe wherein in external system comprising analyzing the corresponding credit evaluation of obtained different user in advance
Breath；Or recorded according to user to be settled a claim in the corresponding Claims Resolution of multiple consumer fields, determine the credit evaluation of user to be settled a claim
Information.
For example, external system according to user different insurance companies history settlement of insurance claim situation, Comprehensive Assessment user's
Credit evaluation information, specifically can be weighted summation according to user in the corresponding credit scoring of different insurance companies, then
It is averaged to obtain the credit evaluation information of the user, the weight of each insurance company can be set according to the actual requirements.
For another example settlement of insurance claim of the acceptable basis user to be settled a claim in shopping at network, solid shop/brick and mortar store shopping, TV shopping etc.
Record, analysis obtain the credit evaluation information of the user, if user often carries out net purchase settlement of insurance claim, freight charges are nearly compensated, real
Body shop shopping items reparation etc., it may be determined that the credit rating of the user is relatively low.
In order to accelerate processing progress of the insurance company server to Claims Resolution request, in the alternative embodiment of the application
In, before the medical bills information in obtaining Claims Resolution request and the corresponding policy information of inquiry, it can also include：Inquire about hospital side
Whether predetermined straight knot service agreement has been signed with insurance company in the corresponding hospital side of client；If hospital Fang Wei is signed with insurance company
Predetermined straight knot service agreement is ordered, then sends Claims Resolution request failure response information to hospital side's client；If hospital side with insurance
Company signs predetermined straight knot service agreement, then obtains the medical bills information in Claims Resolution request again and inquire about corresponding policy information.
In the present embodiment, insurance company can sign straight knot service agreement, the insurance company after subscribing to the agreement with hospital
Corresponding straight knot Claims Resolution operation could subsequently be carried out.For example, receive what hospital side's client was sent in insurance company server
When Claims Resolution is asked, it can inquire about whether client corresponding hospital side in hospital side's has signed predetermined straight knot clothes with insurance company first
Business agreement, if not contracting straight knot service agreement, directly can send Claims Resolution to hospital side's client and ask failure response letter
Breath, notifies its Claims Resolution request failure；If straight knot service agreement of contracting, then carry out subsequent operation.In this way can be with
Accelerate processing progress of the insurance company server to Claims Resolution request, directly carried out for some undesirable Claims Resolution requests
Filter, mitigates the burden of insurance company server, alleviates corresponding request processing pressure.
Further, in order to find the Claims Resolution case of directly knot Claims Resolution operating mistake in time, in the optional reality of the application
Apply in example, after step 103, can also include：The Claims Resolution case to having completed directly knot Claims Resolution operation is spaced to schedule
Part is adjusted；There is the relevant information of abnormal Claims Resolution case in record, and execution cost is demanded or the related behaviour of costs reimbursement
Make.Wherein, predetermined time interval can be set according to the actual requirements, such as complete directly knot Claims Resolution operation to the same day daily
Claims Resolution case adjusted, examination to the amount for which loss settled Claims Resolution case that there are errors in computation, if amount for which loss settled is more than billing amount,
Expense subsequently can be carried out to user from insurance company or hospital to demand, to prevent the economic interests of insurance company from receiving damage
Lose；If amount for which loss settled is less than billing amount, subsequently costs reimbursement can be carried out to user, to ensure the interests of user.
Further, in order to find the Claims Resolution case that there is straight knot Claims Resolution operation failure, so that staff carries out in time
Solve, avoid the Claims Resolution processing progress of user to be settled a claim from being affected, in the alternative embodiment of the application, step 103
Afterwards, can also include：The relevant information of the Claims Resolution case of the straight knot Claims Resolution operation failure of statistics；According to the logical of Claims Resolution maintenance module
Letter mode information, is pushed to Claims Resolution maintenance module by the relevant information of the Claims Resolution case of the straight knot Claims Resolution operation failure in real time.
Wherein, the relevant information for case of settling a claim can include Claims Resolution docket, Claims Resolution content, user's medical bills information, Yong Hubao
Single information, Claims Resolution operation failure reason etc.；Can settle a claim according to the relevant information of case of Claims Resolution maintenance module analyze
To the unit module for solving straight knot Claims Resolution operation failure, concrete processing procedure may refer to processing mode of the prior art,
This is repeated no more；Communication method information can include the E-mail address (Electronic MAIL, E-mail) of Claims Resolution maintenance module
Address, IP address, telephone number, the account etc. of instant messaging tools.
In the present embodiment, can be by the relevant information of the Claims Resolution case when Claims Resolution operation failure occurs for case of settling a claim
Claims Resolution maintenance module is pushed in time to be handled, and to be solved in time to it, ensures the Claims Resolution efficiency of medical insurance.
Further, the specific implementation as Fig. 1 the methods, the embodiment of the present application provide one kind and are based on medical insurance
Claims Resolution device, as shown in Fig. 2, described device includes：Acquiring unit 21, query unit 22, detection unit 23, Claims Resolution unit
24。
Acquiring unit 21, can be used for when insurance company server receives the Claims Resolution request of hospital side's client transmission
When, the medical bills information of the user to be settled a claim carried in the acquisition Claims Resolution request；
Query unit 22, can be used for the policy information of user to be settled a claim described in inquiry；
Detection unit 23, can be used for being looked into according to the policy information and the query unit 22 of the acquiring unit 21 acquisition
Whether the medical bills information ask, user to be settled a claim described in detection meet predetermined straight knot condition；
Claims Resolution unit 24, if can be used for detection unit 23 detects that the user to be settled a claim meets predetermined straight knot condition,
Then the bill in the medical bills information is detailed, and is limited in the policy information with the detailed corresponding Claims Resolution of the bill
Volume and Claims Resolution ratio, determine the corresponding amount for which loss settled of the user to be settled a claim, and corresponding straight according to amount for which loss settled progress
Knot Claims Resolution operation.
In specific application scenarios, in order to ensure the security of directly knot Claims Resolution operation, the straight knot reason of insurance company is reduced
Risk is paid for, as shown in figure 3, detection unit 23 can specifically include：Detection module 231, determining module 232；
Detection module 231, can be used for according to the policy information, the medical insurance of user's purchase to be settled a claim described in inquiry
Product information, and detect whether the medical insurance product information supports preset straight knot service；And/or according to the medical bills
Bill in information is detailed, and detailed with the bill corresponding Claims Resolution limit and Claims Resolution ratio in the policy information, detection
Whether the amount of money for needing to settle a claim is more than the maximum Claims Resolution limit of the medical insurance product information；And/or wait to settle a claim described in detection
Whether user is preset straight knot Claims Resolution black list user；And/or the insurance of user to be settled a claim within a predetermined period of time described in detection
Whether claim times are more than predetermined times threshold value；
Determining module 232, can be used for when the preset straight knot of medical insurance product information support services, and/or described
The amount of money for needing to settle a claim is less than or equal to the maximum Claims Resolution limit of the medical insurance product information, and/or described treats that Claims Resolution is used
Family is not that preset straight knot Claims Resolution black list user, and/or the settlement of insurance claim number are less than the predetermined times threshold value, determines institute
State user to be settled a claim and meet predetermined straight knot condition.
In specific application scenarios, in order to further ensure the security of straight knot Claims Resolution operation, as shown in figure 3, detection
Unit 23 specifically further includes：Acquisition module 233；
Acquisition module 233, can be used for the credit evaluation information of user to be settled a claim described in obtaining；
Detection module 231, can be used for according to the credit evaluation information, the credit scoring of user to be settled a claim described in detection
Whether predetermined scoring threshold value is greater than or equal to, and/or whether the credit evaluation grade of the user to be settled a claim is greater than or equal in advance
Determine grade threshold；
Determining module 232, can be used for when the credit scoring is less than the predetermined scoring threshold value, and/or the credit
When evaluation grade is less than the predetermined grade threshold, determine that the user to be settled a claim does not meet predetermined straight knot condition.
In specific application scenarios, in order to acquire more accurate, more comprehensively user credit assessment to be settled a claim
Information, as shown in figure 3, acquisition module 233, specifically can be used for by inquiring about external system, user to be settled a claim described in acquisition
Credit evaluation information, comprising analyzing the obtained corresponding credit evaluation information of different user in advance in the external system；
Or recorded according to the user to be settled a claim in the corresponding settlement of insurance claim of multiple consumer fields, determine the user's to be settled a claim
Credit evaluation information.
In specific application scenarios, as shown in figure 3, described device further includes：Transmitting element 25.
Query unit 22, can be also used for inquiring about the corresponding hospital side of hospital side's client whether with insurance company
Sign predetermined straight knot service agreement；
Transmitting element 25, is signed in advance if can be used for the query unit 22 and inquire hospital Fang Wei with the insurance company
Fixed straight knot service agreement, then send Claims Resolution request failure response information to hospital side's client；
Acquiring unit 21, is signed with the insurance company if specifically can be used for the query unit 22 and inquire hospital side
Predetermined straight knot service agreement is ordered, then obtains the medical bills information of the user to be settled a claim carried in the Claims Resolution request.
In specific application scenarios, in order to find the Claims Resolution case of directly knot Claims Resolution operating mistake in time, as shown in figure 3,
Described device further includes：Accounting unit 26, recording unit 27；
Accounting unit 26, can be used for being spaced the Claims Resolution case progress to having completed directly knot Claims Resolution operation to schedule
Adjust；
Recording unit 27, can be used for the relevant information that record has abnormal Claims Resolution case, and execution cost demand or
The relevant operation of costs reimbursement.
In specific application scenarios, as shown in figure 3, described device further includes：Statistic unit 28, push unit 29；
Statistic unit 28, can be used for the relevant information for counting the Claims Resolution case of straight knot Claims Resolution operation failure；
Push unit 29, can be used for the communication method information according to Claims Resolution maintenance module, in real time by the straight knot Claims Resolution
The relevant information of the Claims Resolution case of operation failure is pushed to Claims Resolution maintenance module.
It should be noted that each function involved by a kind of Claims Resolution device based on medical insurance provided by the embodiments of the present application
Other corresponding descriptions of unit, may be referred to the corresponding description in Fig. 1, details are not described herein.
Based on above-mentioned method as shown in Figure 1, correspondingly, the embodiment of the present application additionally provides a kind of storage device, deposit thereon
Computer program is contained, which realizes the above-mentioned Claims Resolution method based on medical insurance as shown in Figure 1 when being executed by processor.
Embodiment based on above-mentioned method as shown in Figure 1 and virtual bench as shown in Figure 2, to achieve these goals, this
Application embodiment additionally provides a kind of entity apparatus based on medical insurance Claims Resolution, which includes storage device and processing
Device；The storage device, for storing computer program；The processor, for performing the computer program to realize
State the Claims Resolution method as shown in Figure 1 based on medical insurance.
Further, based on such scheme, the embodiment of the present application additionally provides a kind of Claims Resolution system based on medical insurance,
As shown in figure 4, the system includes：Insurance company server 31, hospital side's client 32；
Hospital side's client 32, can be used for the medical bills information for obtaining user；According in the medical bills information
User identifier, inquire about the user whether insured medical insurance；If so, then the user is determined as to treat that Claims Resolution is used
Family, and the Claims Resolution request for carrying user's medical bills information to be settled a claim is sent to the insurance company server 31；Example
Such as, hospital side's client can inquire about mark (such as user's name, identification card number that whether there is the user in list of having insured
Code etc.), wherein, the corresponding mark of different user of insured medical insurance is preserved in the list of having insured, and
Corresponding place insurance product information；If there are the mark of the user in list of having insured, it is determined that the user is
Insured medical insurance.
Insurance company server 31, the Claims Resolution that can be used for receiving hospital side's client transmission are asked, and
According to the policy information of the user to be settled a claim and the medical bills information, determine that the user to be settled a claim meets predetermined straight knot
After condition, corresponding straight knot Claims Resolution operation is carried out according to the corresponding amount for which loss settled of the user to be settled a claim.
By the technical solution of application the application, compared with the Claims Resolution mode of traditional medical insurance, without treating that Claims Resolution is used
Hu Zaiqu insurance companies carry out Claims Resolution accounting, save settlement of insurance claim settlement time, improve the Claims Resolution efficiency of medical insurance, this
Sample user may not need payment or partial payment in advance and give hospital relevant medical expense, it is possible to realizes to go to a doctor and sees a doctor, greatly
The experience for enhancing user.
Through the above description of the embodiments, those skilled in the art can be understood that the application can lead to
Hardware realization is crossed, the mode of necessary general hardware platform can also be added by software to realize.Based on such understanding, this Shen
Technical solution please can be embodied in the form of software product, which can be stored in a non-volatile memories
In medium (can be CD-ROM, USB flash disk, mobile hard disk etc.), including some instructions are used so that a computer equipment (can be
Personal computer, server, or network equipment etc.) perform each implement scene of the application described in method.
It will be appreciated by those skilled in the art that attached drawing is a schematic diagram for being preferable to carry out scene, module in attached drawing or
Flow is not necessarily implemented necessary to the application.
It will be appreciated by those skilled in the art that the module in device in implement scene can be described according to implement scene into
Row is distributed in the device of implement scene, can also carry out one or more dresses that respective change is disposed other than this implement scene
In putting.The module of above-mentioned implement scene can be merged into a module, can also be further split into multiple submodule.
Above-mentioned the application sequence number is for illustration only, does not represent the quality of implement scene.
Disclosed above is only several specific implementation scenes of the application, and still, the application is not limited to this, Ren Heben
What the technical staff in field can think change should all fall into the protection domain of the application.
Claims (10)
- A kind of 1. Claims Resolution method based on medical insurance, it is characterised in that including：When insurance company server receives the Claims Resolution request that hospital side's client is sent, obtain and carried in the Claims Resolution request User to be settled a claim medical bills information；AndThe policy information of user to be settled a claim described in inquiry；According to the policy information and the medical bills information, whether user to be settled a claim described in detection meets predetermined straight knot bar Part；If so, then bill in the medical bills information is detailed, and in the policy information it is right with the bill detail The Claims Resolution limit and Claims Resolution ratio answered, determine the corresponding amount for which loss settled of the user to be settled a claim, and according to the amount for which loss settled into The corresponding straight knot Claims Resolution operation of row.
- 2. according to the method described in claim 1, it is characterized in that, described believe according to the policy information and the medical bills Whether breath, user to be settled a claim described in detection meet predetermined straight knot condition, including：According to the policy information, the medical insurance product information of user's purchase to be settled a claim described in inquiry, and detect the medical treatment Whether insurance product information supports preset straight knot service；And/orBill in the medical bills information is detailed, and Claims Resolution corresponding with bill detail in the policy information Whether limit and Claims Resolution ratio, the amount of money that detection needs to settle a claim are more than the maximum Claims Resolution limit of the medical insurance product information； And/orWhether user to be settled a claim described in detection is preset straight knot Claims Resolution black list user；And/orWhether the settlement of insurance claim number of user to be settled a claim described in detection within a predetermined period of time is more than predetermined times threshold value；When the medical insurance product information supports preset straight knot service, and/or the amount of money for needing to settle a claim to be less than or equal to The maximum Claims Resolution limit of the medical insurance product information, and/or the user to be settled a claim are not preset straight knot Claims Resolution blacklists User, and/or the settlement of insurance claim number are less than the predetermined times threshold value, determine that the user to be settled a claim meets predetermined straight knot Condition.
- 3. according to the method described in claim 2, it is characterized in that, described believe according to the policy information and the medical bills Whether breath, user to be settled a claim described in detection meet predetermined straight knot condition, further include：The credit evaluation information of user to be settled a claim described in acquisition；According to the credit evaluation information, whether the credit scoring of user to be settled a claim described in detection is greater than or equal to predetermined scoring threshold Whether value, and/or the credit evaluation grade of the user to be settled a claim are greater than or equal to predetermined grade threshold；When the credit scoring is less than the predetermined grade less than the predetermined scoring threshold value, and/or the credit evaluation grade During threshold value, determine that the user to be settled a claim does not meet predetermined straight knot condition.
- 4. the according to the method described in claim 3, it is characterized in that, credit evaluation letter of user to be settled a claim described in the acquisition Breath, including：By inquiring about external system, the credit evaluation information of user to be settled a claim described in acquisition, comprising advance in the external system Analyze the obtained corresponding credit evaluation information of different user；OrUser to be settled a claim is in the corresponding settlement of insurance claim record of multiple consumer fields, the definite user to be settled a claim according to described in Credit evaluation information.
- 5. according to the method described in claim 1, it is characterized in that, what is carried in the acquisition Claims Resolution request treats that Claims Resolution is used Before the medical bills information at family, the method further includes：Inquire about whether the corresponding hospital side of hospital side's client has signed predetermined straight knot service agreement with insurance company；If the hospital Fang Wei signs predetermined straight knot service agreement with the insurance company, sent to hospital side's client Claims Resolution request failure response information；The medical bills information for obtaining the user to be settled a claim carried in the Claims Resolution request, including：If the hospital side has signed predetermined straight knot service agreement with the insurance company, obtain and carried in the Claims Resolution request User to be settled a claim medical bills information.
- 6. according to the method described in claim 1, it is characterized in that, described carry out corresponding straight knot reason according to the amount for which loss settled After paying for operation, the method further includes：It is spaced to schedule and the Claims Resolution case for having completed directly knot Claims Resolution operation is adjusted；There is the relevant information of abnormal Claims Resolution case in record, and execution cost is demanded or the relevant operation of costs reimbursement.
- 7. method according to any one of claim 1 to 6, it is characterised in that described to be carried out according to the amount for which loss settled After corresponding straight knot Claims Resolution operation, the method further includes：The relevant information of the Claims Resolution case of the straight knot Claims Resolution operation failure of statistics；According to the communication method information of Claims Resolution maintenance module, in real time by the correlation of the Claims Resolution case of the straight knot Claims Resolution operation failure Information is pushed to Claims Resolution maintenance module.
- 8. a kind of Claims Resolution system based on medical insurance, it is characterised in that including the guarantor any one of claim 1 to 7 Dangerous corporate server and hospital side's client；Hospital side's client, for obtaining the medical bills information of user；According to the user in the medical bills information Whether mark, inquire about the user insured medical insurance；If so, the user is then determined as user to be settled a claim, and to The insurance company server sends the Claims Resolution request for carrying user's medical bills information to be settled a claim；The insurance company server, the Claims Resolution request sent for receiving hospital side's client, and according to institute The policy information of user to be settled a claim and the medical bills information are stated, determines that the user to be settled a claim meets predetermined straight knot condition Afterwards, corresponding straight knot Claims Resolution operation is carried out according to the corresponding amount for which loss settled of the user to be settled a claim.
- 9. a kind of storage device, is stored thereon with computer program, it is characterised in that is realized when described program is executed by processor The Claims Resolution method based on medical insurance any one of claim 1 to 7.
- 10. a kind of server, including storage device, processor and storage are on a storage device and the meter that can run on a processor Calculation machine program, it is characterised in that the processor realizes the base any one of claim 1 to 7 when performing described program In the Claims Resolution method of medical insurance.
Priority Applications (2)
| Application Number | Priority Date | Filing Date | Title |
|---|---|---|---|
| CN201711110993.8A CN107909487A (en) | 2017-11-10 | 2017-11-10 | Claims Resolution method, apparatus and system based on medical insurance |
| PCT/CN2018/074619 WO2019090983A1 (en) | 2017-11-10 | 2018-01-30 | Claim settlement method, apparatus and system based on medical insurance |
Applications Claiming Priority (1)
| Application Number | Priority Date | Filing Date | Title |
|---|---|---|---|
| CN201711110993.8A CN107909487A (en) | 2017-11-10 | 2017-11-10 | Claims Resolution method, apparatus and system based on medical insurance |
Publications (1)
| Publication Number | Publication Date |
|---|---|
| CN107909487A true CN107909487A (en) | 2018-04-13 |
Family
ID=61845205
Family Applications (1)
| Application Number | Title | Priority Date | Filing Date |
|---|---|---|---|
| CN201711110993.8A Pending CN107909487A (en) | 2017-11-10 | 2017-11-10 | Claims Resolution method, apparatus and system based on medical insurance |
Country Status (2)
| Country | Link |
|---|---|
| CN (1) | CN107909487A (en) |
| WO (1) | WO2019090983A1 (en) |
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