CN109559237A - The method and apparatus of drug reimbursement Information abnormity - Google Patents
The method and apparatus of drug reimbursement Information abnormity Download PDFInfo
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- 239000003814 drug Substances 0.000 title claims abstract description 645
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- 238000002347 injection Methods 0.000 description 17
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- 229960000598 infliximab Drugs 0.000 description 13
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Abstract
The present invention provides the method and apparatus for determining drug reimbursement Information abnormity, wherein, method includes: to obtain the drug protection amount settlement request for being directed to target medicine, drug protection amount settlement request includes the weight information of the identity information of preset state user, the corresponding reimbursement information of target medicine and preset state user, determines that compensation protection amount and accumulative reimbursement of the preset state user within the reimbursement period of target medicine are insured amount according to identity information and reimbursement information；Single dosage is determined according to weight information and usage and dosage rule；The corresponding reimbursement thresholding of target medicine and reimbursement time limit are determined according to protection amount, drug Huimin rule, single dosage has been paid for, and reimbursement thresholding, which is greater than or equal to, has paid for protection amount；If insured amount settlement request meets reimbursement time limit, also, accumulative reimbursement protection amount is greater than reimbursement thresholding, it is determined that drug protection amount settlement request has abnormal, sending reimbursement abnormal prompt.Technical solution of the present invention can reduce insurance fraud behavior.
Description
Technical field
The present invention relates to medical fields, more particularly to the method for determining drug reimbursement Information abnormity.
Background technique
With the development of society and the continuous promotion of living standards of the people, people gradually start to receive miscellaneous insurance
Project is especially valued by the people especially for ensureing the medical insurance of basic medical demand.Existing medical insurance is main
There are two types of, the commercial medical insurance including the profitability that the social medical insurance established by state and society and enterprise are established.It is right
For the user for having participated in medical insurance, when its illness, user can be produced disease according to the Claims Resolution rule of medical insurance
Raw medical expense is submitted an expense account, to alleviate the economic pressures generated by illness to a certain extent.
In current commercial medical insurance Claims Resolution policy, for certain special drugs for being included in Claims Resolution range, usually
By healthcare structure after the identity for having verified illness user and medical qualification, these special drugs needed for illness user are mentioned
User is supplied, then again by medical institutions according to the drug for being supplied to illness user medical insurance machine corresponding with illness user
Structure is settled a claim.Be likely to occur following problem in this way: due to certain drugs have it is certain give policy (such as buying one and geing one free), give
Drug not can be carried out Claims Resolution, these medicines that medical institutions may will give when settling a claim to Medical Insurance Organizations really
Product are also included in Claims Resolution range, i.e. insurance fraud behavior can additionally increase the Claims Resolution expenditure of Medical Insurance Organizations in this way.
Summary of the invention
The embodiment of the present invention provides the method and apparatus for determining drug reimbursement Information abnormity, and solution is led because of insurance fraud behavior
The problem of increasing, is paid in the Claims Resolution of the Medical Insurance Organizations of cause.
In a first aspect, providing a kind of method of determining drug reimbursement Information abnormity, comprising:
The drug protection amount settlement request for being directed to target medicine is obtained, the drug protection amount settlement request includes that preset state is used
The corresponding reimbursement information of the identity information at family, the target medicine and the weight information of the preset state user；
Determine the preset state user in institute according to the identity information of the preset state user and the reimbursement information
It states the protection amount of compensation in the reimbursement period of target medicine and adds up reimbursement protection amount, it is described to have paid for the insured amount and described accumulative reimbursement protection amount
It is the corresponding protection amount of the target medicine, the accumulative reimbursement for submitting an expense account the target medicine in the corresponding period in period is protected
Volume is not reset；
The usage and dosage rule of the target medicine is obtained, and according to the weight information and usage and dosage rule
Determine the corresponding single dosage of the preset state user；
Obtain the target medicine corresponding drug Huimin rule, and according to paid for insured amount, described drug Huimin rule with
And the single dosage determines the corresponding reimbursement thresholding of the target medicine, the reimbursement thresholding be greater than or equal to it is described
Pay for insured amount, the drug Huimin rule is to buy the quantity of the target medicine to reach corresponding number of preset paid drug period
After amount, giving quantity is that the target medicine of corresponding quantity of preset free drug period gives preset state user, drug period
For reflecting that user uses attainable treatment degree after drug；
The corresponding reimbursement time limit of the target medicine is determined according to the reimbursement thresholding and the drug Huimin rule, it is described
Reimbursement time limit is less than or equal to the reimbursement period；
If the drug protection amount settlement request is within the reimbursement time limit corresponding time, also, the accumulative reimbursement
Protection amount is greater than the reimbursement thresholding, it is determined that the drug protection amount settlement request has abnormal, sending reimbursement abnormal prompt.
In the embodiment of the present invention, time when by the accumulative reimbursement protection amount to target medicine and settling accounts judges,
It can determine whether the accumulative compensation protection amount of the target medicine alreadys exceed the thresholding amount of reimbursement, and determine the time of clearing
Whether in using the validity period of drug given, when the accumulative compensation protection amount of target medicine be more than the thresholding amount of reimbursement simultaneously
And time of clearing when being in the validity period of drug given, illustrate that the reimbursement of this part may submit an expense account is the drug given
Expense, issuing reimbursement abnormity prompt can make the personnel for being responsible for Claims Resolution notice this abnormal conditions, so as to the situation
It is verified, prevents insurance fraud, it to a certain extent can be to avoid the additional Claims Resolution expenditure for increasing Medical Insurance Organizations.
With reference to first aspect, in one possible implementation, described according to the weight information and the usage
Dosage rule determines the corresponding single dosage of the preset state user, comprising: determines in the usage and dosage rule
Using weight as the unit dosage of medication unit；By the product of the weight information corresponding weight and the unit dosage
It is determined as the corresponding single dosage of the preset state user.By the unit dosage and weight that determine target medicine
Information can determine the dosage of user's first use target medicine.
With reference to first aspect, in one possible implementation, the method also includes: if the drug protection amount knot
Request is calculated within the reimbursement time limit corresponding time, alternatively, the accumulative reimbursement is insured amount to be less than the reimbursement thresholding, then by institute
The corresponding reimbursement business datum of reimbursement information is stated to transfer to the business number of the corresponding medical institutions of the drug protection amount settlement request
According in account.It is transferred by the way that the corresponding reimbursement business datum of information will be submitted an expense account into the business datum account of medical institutions, it can be with
Realize normal reimbursement process.
With reference to first aspect, in one possible implementation, the basis has paid for insured amount, the described drug Huimin rule
And the single dosage determines that the corresponding reimbursement thresholding of the target medicine includes: true according to the drug Huimin rule
Determine the target medicine corresponding paid drug period；Institute is determined according to the paid drug period and the single dosage
State the corresponding paid Quantity of drugs of target medicine；Determine that the first expense, first expense are that quantity is the paid drug number
The corresponding drug total cost of the target medicine of amount；The target medicine pair is determined according to protection amount and first expense of having paid for
The reimbursement thresholding answered, the corresponding reimbursement door of the target medicine are limited to N times of the first expense, and N is just whole more than or equal to 1
Number.Paid Quantity of drugs is the quantity for the drug for needing expense to buy, and the medicine of the needs expense is bought by determining
Expense needed for the drug of the quantity of product and protection amount is paid for, can determine and pay for reimbursement thresholding corresponding to protection amount.
With reference to first aspect, in one possible implementation, described according to the reimbursement thresholding and the drug favour
People's rule determines that the corresponding reimbursement time limit of the target medicine includes: to determine the target medicine according to the drug Huimin rule
Corresponding paid drug period and free drug period；Determine that the target medicine period is corresponding using duration, the target medicine
Period is that quantity is the sum of the paid drug period and free drug period；According to the reimbursement thresholding and it is described use duration
Determine that the corresponding reimbursement time limit of the target medicine, the reimbursement time limit are M times using duration, M is more than or equal to 1
Positive integer.By the period and the period for the drug given of the drug that the needs that determining Huimin rule defines are bought, two are determined
Kind of period corresponding total duration in conjunction with the duration and has paid for protection amount and can determine the corresponding reimbursement time limit of the target medicine.
With reference to first aspect, in one possible implementation, after the sending reimbursement abnormal prompt further include: root
The prompt duration of the reimbursement abnormal prompt is determined according to the drug protection amount settlement request and the reimbursement time limit；Passing through
After period of the time span for the prompt duration, the reimbursement abnormal prompt is unlocked.By continue in prompt
Reimbursement abnormal prompt is released after one section of duration, can make the available reimbursement of drug in normally Claims Resolution range.
With reference to first aspect, in one possible implementation, the method also includes: determine in the reimbursement period
The corresponding maximum compensation amount of the interior target medicine；If the accumulative reimbursement is insured amount to be greater than the maximum compensation amount,
Freeze or refuse the drug protection amount settlement request.It, can be to avoid mistake by determining maximum amount of the drug in a reimbursement
Degree reimbursement, to prevent insurance fraud behavior.
With reference to first aspect, in one possible implementation, determination target within the reimbursement period
The corresponding maximum amount of compensating of drug includes: according to the usage and dosage rule, single dosage and the drug Huimin
Rule determines the corresponding paid Quantity of drugs of maximum of the target medicine described within the reimbursement period；It is that the maximum has by quantity
The corresponding drug total cost of target medicine for repaying Quantity of drugs is determined as maximum of the target medicine within the reimbursement period
Compensate amount.By determining that expense corresponding to maximum Quantity of drugs with compensation and the drug by the quantity is determined as maximum compensation volume
Degree guarantees the available reimbursement of drug in normally Claims Resolution range under the premise of avoiding excessively submitting an expense account.
With reference to first aspect, in one possible implementation, described according to the usage and dosage rule, single medication
Dosage and the drug Huimin rule determine the corresponding maximum paid drug number of the target medicine described within the reimbursement period
Amount includes: to determine the target medicine within the reimbursement period according to the single dosage and the usage and dosage rule
Corresponding drug total quantity；It is determined according to the drug total quantity and the drug Huimin rule described within the reimbursement period
The corresponding paid Quantity of drugs of maximum of target medicine.
Second aspect provides a kind of device of determining drug reimbursement Information abnormity, comprising:
Request module, for obtaining the drug protection amount settlement request for being directed to target medicine, the drug protection amount clearing
Request includes identity information, the corresponding reimbursement information of the target medicine and the preset state user of preset state user
Weight information；
Protection amount compensates determining module, for being determined according to the identity information of the preset state user and the reimbursement information
Compensation protection amount and accumulative reimbursement of the preset state user within the reimbursement period of the target medicine are insured amount, described to have paid for guarantor
Volume and the accumulative reimbursement protection amount are the corresponding protection amount of the target medicine, described in the corresponding period in reimbursement period
The accumulative reimbursement protection amount of target medicine is not reset；
Dosage determining module for obtaining the usage and dosage rule of the target medicine, and is believed according to the weight
Breath and the usage and dosage rule determine the corresponding single dosage of the preset state user；
Thresholding amount determining module for obtaining the corresponding drug Huimin rule of the target medicine, and is protected according to having paid for
Volume, drug Huimin rule and the single dosage determine the corresponding reimbursement thresholding of the target medicine, the report
Pin thresholding be greater than or equal to it is described paid for protection amount, the drug Huimin rule is to buy the quantity of the target medicine to reach default
Corresponding quantity of paid drug period after, give target medicine that quantity is corresponding quantity of preset free drug period to
Preset state user, the drug period is for reflecting that user uses attainable treatment degree after drug；
Reimbursement time limit determining module, for determining the target medicine according to the reimbursement thresholding and the drug Huimin rule
The corresponding reimbursement time limit of product, the reimbursement time limit are less than or equal to the reimbursement period；
Abnormal determining module, if for the drug protection amount settlement request within the reimbursement time limit corresponding time,
Also, the accumulative reimbursement is insured amount to be greater than the reimbursement thresholding, it is determined that the drug protection amount settlement request has abnormal, sending
Submit an expense account abnormal prompt.
The third aspect, provides another device for determining drug reimbursement Information abnormity, including processor, memory and logical
Believe interface, the processor, memory and communication interface are connected with each other, wherein the communication interface is for receiving or sending number
According to the device that the memory is used to store determining drug reimbursement Information abnormity executes the application code of the above method, institute
State the method that processor is configured for executing above-mentioned first aspect.
Fourth aspect provides a kind of computer storage medium, and the computer storage medium is stored with computer program, institute
Stating computer program includes program instruction, and described program instruction makes the processor execute above-mentioned first when being executed by a processor
The method of aspect.
In the embodiment of the present invention, by judge currently submit an expense account whether be the drug given expense, be to give in determination
Drug expenditure when, then issue abnormal prompt, can make be responsible for Claims Resolution personnel notice this abnormal conditions, so as to right
The situation is verified, and insurance fraud is prevented, to a certain extent can be to avoid the additional Claims Resolution expenditure for increasing Medical Insurance Organizations.
Detailed description of the invention
It to describe the technical solutions in the embodiments of the present invention more clearly, below will be to needed in the embodiment
Attached drawing is briefly described, it should be apparent that, drawings in the following description are only some embodiments of the invention, for ability
For the those of ordinary skill of domain, without creative efforts, it can also be obtained according to these attached drawings other attached
Figure.
Fig. 1 is a kind of flow diagram of the method for determining drug reimbursement Information abnormity that inventive embodiments provide；
Fig. 2 is the flow diagram of another method for determining drug reimbursement Information abnormity provided in an embodiment of the present invention；
Fig. 3 is a kind of composed structure signal of the device of determining drug reimbursement Information abnormity provided in an embodiment of the present invention
Figure；
Fig. 4 is the composed structure signal of another device for determining drug reimbursement Information abnormity provided in an embodiment of the present invention
Figure.
Specific embodiment
Following will be combined with the drawings in the embodiments of the present invention, and technical solution in the embodiment of the present invention carries out clear, complete
Site preparation description, it is clear that the described embodiment is only a part of the embodiment of the present invention, instead of all the embodiments.Based on this
Embodiment in invention, every other reality obtained by those of ordinary skill in the art without making creative efforts
Example is applied, shall fall within the protection scope of the present invention.
The technical solution of the embodiment of the present invention is suitable for the reimbursement of usage and dosage rule drug related with the weight of user
The detection of Information abnormity.
Before introducing the scheme of the embodiment of the present invention, first to the present embodiments relate to several concepts be situated between
It continues.
1, the concept in period is submitted an expense account
The reimbursement period refers to that the protection amount compensated within its corresponding period is accumulated, also, right by its
After the period answered, the period reset to the protection amount is needed.In some possible implementations, the reimbursement period can be should
The insurance period of the corresponding medical insurance of drug.For example, the insurance period of the corresponding medical insurance of the drug is 1 year, then submit an expense account
Period is 1 year.
2, drug Huimin rule
Drug Huimin rule is to manufacture the manufacturer or related medical management organization (such as social security office, administration of health department of drug
Deng) for what the drug was formulated some preferential give medicine rule.Such as it buys one and present one, buy and three give one, buy five and give three, etc..Its
In, drug Huimin rule can with Quantity of drugs be give unit, with Quantity of drugs be give unit refer to the drug given with
Measurement unit when drug is sold is unit.For example, then drug Huimin rule is to buy three using bottle as measurement unit when drug is sold
Bottle gives one bottle, buys five bottles and gives one bottle；For another example, using box as measurement unit when drug is sold, then drug Huimin rule can be to buy five
Box gives three boxes, buys five boxes and gives box, etc..Drug Huimin rule can also be to give unit with the drug period, be given with drug
As unit of unit refers to that the medication cycle by drug refers to the drug the given drug period corresponding to the drug, the drug period
To can reflect a period of time using attainable treatment degree after drug.For example, using the attainable treatment journey of drug
Degree indicates that then drug Huimin rule is to buy for three periods to give a period with the period, bought for five periods and gives a period；For another example, using medicine
The attainable treatment degree of product indicates that then drug Huimin rule is to buy five courses for the treatment of to give three courses for the treatment of with the course for the treatment of, buys a course for the treatment of and gives one
Course for the treatment of, etc..
3, the concept of thresholding and reimbursement time limit is submitted an expense account
Reimbursement door be limited to according to the usage and dosage rule of drug and drug give that rule determines for measuring accumulative compensation
Pay it is insured amount whether reasonable expense thresholding.Reimbursement time limit is corresponding with reimbursement thresholding, and reimbursement time limit is the usage and dosage according to drug
Rule and drug give that rule determines for measuring whether the time settled accounts is in the validity period given of the drug given
Period.The time that the time span of reimbursement time limit corresponding period is less than or equal to the corresponding period in reimbursement period is long
Degree.The reimbursement time limit corresponding time is to submit an expense account the initial time in period to begin to pass through arrival after the corresponding duration of the reimbursement time limit
Time.Reimbursement thresholding and reimbursement time limit and drug to give rule closely related.
It illustrates to be illustrated to reimbursement thresholding and reimbursement time limit.Assuming that the rule of giving of drug is sent one week to buy for three periods
Phase, according to a cycle when it is 2 months a length of, a cycle uses two box drugs, and the unit price of a box drug is 500 yuan.Then report
Pin thresholding is the integral multiple that the expense of the drug of user at one's own expense is needed when user reaches the standard for giving drug, as (500*2) *
3*1, (500*2) * 3*2, (500*2) * 3*3, etc..Reimbursement time limit is corresponding with reimbursement thresholding, and reimbursement door, which is limited to reach, to be given
The integral multiple for the time that the drug for needing the drug of user at one's own expense and increasing to send when drug can use, as 1*2* (3+1) * 1,2*
2* (3+1), etc..
It is a kind of process signal of the method for determining drug reimbursement Information abnormity that inventive embodiments provide referring to Fig. 1, Fig. 1
Figure, as shown, this method comprises:
S101, obtains the drug protection amount settlement request for being directed to target medicine, and the drug protection amount settlement request includes default
The corresponding reimbursement information of the identity information of status user, the target medicine and the weight information of the preset state user.
Here, drug protection amount settlement request is the settlement request that healthcare structure is initiated, can be by receiving medical institutions
The drug protection amount settlement request that checkout apparatus issues is to getting the drug protection amount settlement request, wherein medical institutions can be with
Have for medical insurance fixed hospital, medical insurance fixed point pharmacy etc. and sells the qualification of drug to illness user and have with Medical Insurance Organizations
The mechanism of cooperative relationship.
Target medicine is the drug defined in medical insurance clause in Claims Resolution range, that is, needs Medical Insurance Organizations will
Its corresponding cost transfer to medical institutions account drug.
Preset state user refers to that illness needs to buy the user of the target medicine.The identity information of preset state user be with
The relevant information of the personal identification for showing preset state user of preset state user's unique match.The preset state
The identity information of user can for the ID card No. of preset state user, preset state user fingerprint feature information,
The face feature information, etc. of preset state user.
S102 determines the preset state user according to the identity information of the preset state user and the reimbursement information
The protection amount of compensation and accumulative reimbursement within the reimbursement period of the target medicine is insured amount, described to have paid for the insured amount and accumulative reimbursement
Protection amount is the corresponding protection amount of the target medicine.
Here, the reimbursement period of target medicine be compensated within its corresponding period protection amount accumulated, and
And in the period for after its corresponding period, needing to reset the protection amount.The corresponding doctor of reimbursement period target medicine
Treat the insurance period of insurance.For example, the insurance period of the corresponding medical insurance of the target medicine is 1 year, then the report of target medicine
Selling the period is 1 year.
The insured amount expense to have compensated since the initial time in the reimbursement period for the target medicine is paid for, just
Under reason condition (insurance fraud behavior is not present), this has been paid for protection amount and has bought the target within the reimbursement period equal to preset state user
The expense that drug has been spent.
In the specific implementation, can determine that the compensation within the reimbursement period is protected according to the identity information of preset state user
Then volume determines the corresponding reimbursed sum of reimbursement information, which has been paid for protection amount with this
With the accumulative reimbursement protection amount being determined as within the reimbursement period.
It in one possible implementation, can be each to preset shape according to the identity information of each preset state user
State user individually creates one and compensates information to the drug of the various drugs of preset state user for storing to have compensated
User compensates information data table.It can determine according to the identity information of preset state user and believe with the identity of preset state user
It ceases corresponding user and compensates information data table, it is corresponding then to obtain the target medicine from user compensation information data table
It pays for insured amount, determines it as within the reimbursement period of the target medicine that the preset state user is corresponding to have paid for protection amount.
For example, current one shares 10000 users and compensates information data tables, respectively user compensate information data table 1~
10000, user compensates information data table 1~10000 and respectively corresponds identity information 1~10000, the identity of preset state user
Information is identity information 100, then user corresponding with identity information 100 is compensated information data table 100 and be determined as the default shape
The corresponding user of state user compensates information data table.It is as shown in table 1 that user compensates information data table 100:
| Claims Resolution drug | Protection amount is paid for |
| Drug 1 | Protection amount 1 is paid for |
| Drug 2 | Protection amount 2 is paid for |
| … | … |
Table 1
Assuming that target medicine is drug 2, it is determined that the corresponding protection amount 2 of having paid for of drug 2 is in the reimbursement of target medicine week
The preset state user is corresponding in phase has paid for protection amount.
It can be that every kind of drug creates one according to the medicine information of every kind of drug in alternatively possible implementation
Information data table is compensated to the drug of the compensation information of each preset state user for storing to have compensated.According to the target medicine
Product can determine that the corresponding drug of the target medicine compensates information data table, then compensated from the drug obtained in information data table with
The identity information of preset state user is corresponding to have paid for protection amount, is determined the reimbursement in the target medicine in the target medicine
The preset state user is corresponding in period has paid for protection amount.
For example, the drug in Claims Resolution range has 1000 kinds, then drug compensates information data table one and shares 1000, respectively
Information data table 1~1000 is compensated for drug, respectively corresponds drug 1~1000.Assuming that the target medicine is drug 125, then
Drug corresponding with drug 125 compensates information data table 125 and is determined as the corresponding drug compensation information data table of the target medicine,
It is as shown in table 2 that drug compensates information data table 125:
| User | Protection amount is paid for |
| User 1 | Protection amount 1 is paid for |
| User 2 | Protection amount 2 is paid for |
| … | … |
Table 2
Assuming that preset state user is user 1, it is determined that the corresponding protection amount 1 of having paid for of user 1 is in the report of the target medicine
The preset state user is corresponding in the pin period has paid for protection amount.
S103, obtains the usage and dosage rule of the target medicine, and is used according to the weight information and the usage
Gauge then determines the corresponding single dosage of the preset state user.
Here, the usage and dosage rule of target medicine refers to the use interval of the target medicine and using weight as medication
The unit dosage of unit.Wherein, the use interval of target medicine refer to twice using the drug time between when
Between be spaced, the dosage for the per weight that the drug is intended for single use is referred to using weight as the unit dosage of medication unit.Example
Such as, target medicine be injection infliximab, be divided between the corresponding use of injection infliximab 2 weeks, 4 weeks and
8 weeks, wherein it is divided into 2 weeks between second of corresponding use, is divided into 4 weeks between second of use corresponding with third time for the first time,
Third time and the 4th time, the 4th time and the 5th time ... be divided into 8 weeks between the N-1 times use corresponding with n-th.Injection Ying Fuli
Xidan resists the corresponding unit dosage using weight as medication unit to be 5 milligrams per kilogram.
In the specific implementation, can be believed according to the weight of the corresponding unit dosage of the target medicine and preset state user
It ceases and determines that the corresponding single dosage of preset state user, the single dosage are equal to the unit dosage and the body
The product of the corresponding weight of weight information.For example, target medicine is injection infliximab, injection infliximab is corresponding
Dosage be 5 milligrams per kilogram, the weight of preset state user is 50 kilograms, it is determined that preset state user is corresponding
Single dosage is 50*5=250 milligrams.
S104 obtains the corresponding drug Huimin rule of the target medicine, and advises according to insured amount, described drug Huimin has been paid for
Then and the single dosage determines that the corresponding reimbursement thresholding of the target medicine, the reimbursement thresholding are greater than or equal to institute
It states and has paid for protection amount, the drug Huimin rule is to buy the quantity of the target medicine to reach preset paid drug period corresponding
Quantity after, giving quantity is that the target medicine of corresponding quantity of preset free drug period gives preset state user, drug
Period is for reflecting that user uses attainable treatment degree after drug.
In the embodiment of the present invention, drug Huimin rule is to give unit with the drug period, is to give unit with the drug period
Drug Huimin rule can be found in foregoing description.The paid drug period is when reaching this drug Huimin rule is corresponding to give standard
The drug for needing user the to buy at one's own expense corresponding drug period.For example, drug Huimin rule is to buy three courses for the treatment of to send a course for the treatment of, then have
Repaying the drug period is 3 courses for the treatment of.The free drug period be given when reaching this drug Huimin rule is corresponding to give standard to
The drug at the family corresponding drug period.For example, drug Huimin rule is to buy three courses for the treatment of to send a course for the treatment of, then the free drug period is one
A course for the treatment of.
In the embodiment of the present invention, according to having paid for, insured amount, drug Huimin is regular and single dosage determines target medicine
Corresponding reimbursement thresholding can be with are as follows: determines the target medicine corresponding paid drug period according to drug Huimin rule；According to paid
Drug period and single dosage determine the corresponding paid Quantity of drugs of target medicine；Determine that the first expense, the first expense are
Quantity is the corresponding drug total cost of target medicine of paid Quantity of drugs；Target medicine is determined according to insured amount and the first expense has been paid for
The corresponding reimbursement thresholding of product, the corresponding reimbursement door of target medicine are limited to N times of the first expense, and N is just whole more than or equal to 1
Number.
In one possible implementation, the case where it is to immobilize that each drug period is using the number of drug
Under, it can be according to the rule of number, the target medicine in a target medicine corresponding drug period using the target medicine
Lattice and the single dosage determine the quantity of the target medicine within a drug period, by the mesh in a drug period
It marks the quantity of drug and the paid drug period product rounds up after counting and is determined as paid Quantity of drugs.
For example, it is assumed that a course for the treatment of is using a target medicine, target medicine is injection infliximab, injection
It is 100 milligrams/bottle with the specification of infliximab, the paid drug period of injection infliximab is 5 courses for the treatment of, single
Secondary dosage be 250 milligrams, it is determined that one the drug period target medicine quantity be 250/100=2.5 bottle, determination
The corresponding paid Quantity of drugs of target medicine isBottle.
In alternatively possible implementation, in the case where it is variable that each drug period is using the number of drug,
It can determine that the number of target medicine target medicine in each drug period in the paid drug period determines respectively to be somebody's turn to do
Target medicine within the paid drug period use the target medicine total degree, then according to the specification of the target medicine with
And the single dosage determines the paid Quantity of drugs in the paid drug period.
For example, the target medicine is injection infliximab, the specification of injection infliximab is 100 millis
Gram/bottle, the paid drug period of injection infliximab are 3 courses for the treatment of, and single dosage is 250 milligrams, wherein the
One course for the treatment of is needed using 1 target medicine, and second course for the treatment of is needed using 2 drugs, and the third course for the treatment of is needed using 1 medicine
Product, it is determined that Quantity of drugs is with compensation
In the specific implementation, the unit price of the target medicine can be determined, by unit price and the paid drug number of the target medicine
The product of amount is determined as the first expense, and N times of the first expense is then determined since N=1, by N times of the first expense and has paid for protection amount
It is compared, has paid for N times of insured amount the first expense until finding to be greater than or equal to, this is greater than or equal to 1 and has paid for insured amount N times
First expense is determined as the corresponding reimbursement thresholding of target medicine.For example, having paid for insured amount is 2000, determine that paid Quantity of drugs is 3,
First expense is 500*3=1500.When N=1, N times of the first expense is 1500, since 1500 less than 2000, by N=2, when N=2
N times of the first expense is 3000, then is determined as the corresponding reimbursement thresholding of target medicine for 3000.
S105, when determining the corresponding reimbursement of the target medicine according to the reimbursement thresholding and the drug Huimin rule
Limit, the reimbursement time limit are less than or equal to the reimbursement period.
In the embodiment of the present invention, determine that the corresponding reimbursement time limit of target medicine can according to reimbursement thresholding and drug Huimin rule
With are as follows: target medicine corresponding paid drug period and free drug period are determined according to drug Huimin rule；Determine target medicine
The product period is corresponding using duration, and the target medicine period is that quantity is the sum of paid drug period and free drug period；According to
Reimbursement thresholding determines the corresponding reimbursement time limit of target medicine with using duration, reimbursement time limit be using M times of duration, M for greater than
Or the positive integer equal to 1.
In one possible implementation, it is fixed at the use interval of drug and each drug period uses drug
In the case that number immobilizes, the target medicine period corresponding mode using duration can be determined according to usage and dosage rule
Are as follows: according to the use for the number and the target medicine for using the target medicine in a target medicine corresponding drug period
It is spaced and determines that a drug period is corresponding using duration, which is determined as target medicine
The product period it is corresponding use duration.For example, using the number of the target medicine in a course for the treatment of is 2 times, which makes
It is divided into 8 weeks with, the paid drug period is 2 courses for the treatment of, and the free drug period is 1 course for the treatment of, it is determined that a drug period pair
A length of 2*8=16 weeks when the use answered, a length of 16* (2+1)=48 week when the corresponding use of target medicine period is determined.
It in alternatively possible implementation, is not fixed at the use interval of drug, alternatively, each drug period uses
In the unfixed situation of the number of drug, when can determine respectively the corresponding use of each drug period according to usage and dosage rule
It is long, each drug period corresponding be determined as the target medicine period using the sum of duration and corresponding use duration.For example, paid
The drug period is 2 courses for the treatment of, and the free drug period is 1 course for the treatment of, wherein it is 5 weeks a length of when the corresponding use of first course for the treatment of, the
3 weeks a length of when the corresponding use of two courses for the treatment of, when third course for the treatment of corresponding use, is 1 week a length of, it is determined that the target medicine period
A length of 9 weeks when corresponding use.
In the specific implementation, it is corresponding to calculate the target medicine period according to the usage and dosage rule of target medicine in advance
The target medicine period corresponding duration is stored in advance duration, is determining that reimbursement door prescribes a time limit, is determining target medicine according to the duration
The corresponding reimbursement time limit of product.
In the specific implementation, can determine that the reimbursement thresholding and quantity are the corresponding drug of the target medicine of paid Quantity of drugs
The ratio of total cost (i.e. the first expense), is determined as the ratio for M, is determined as reimbursement time limit using duration for M times.
For example, reimbursement door is limited to 3000, quantity is that the corresponding drug total cost of target medicine of paid Quantity of drugs is
1500, it is determined that ratio 2 is then determined as reimbursement time limit using duration for 2 times.
S106, it is also, described accumulative if the drug protection amount settlement request is within the reimbursement time limit corresponding time
Reimbursement is insured amount to be greater than the reimbursement thresholding, it is determined that the drug protection amount settlement request has exception, issues reimbursement abnormal prompt.
Here, insured amount settlement request refers to since the initial time in the reimbursement period within the reimbursement time limit corresponding time
It is less than the reimbursement time limit to the time span between time when getting the drug protection amount settlement request.For example, the reimbursement period
Initial time be 00:00:00 on January 1st, 2018, reimbursement time limit be 140 days, then the reimbursement time limit corresponding time be 2018
May 22 00:00:00, if drug protection amount settlement request be 00:00:00 on May 22nd, 2018 before get, the drug
Insured amount settlement request meets reimbursement time limit, otherwise, is then unsatisfactory for reimbursement time limit.
In the specific implementation, report can be issued by prompting modes such as auditory tone cues, page pop-up prompt, distinguishing mark prompts
Sell abnormal prompt.
In a further implementation, it is determining that the drug protection amount settlement request deposits when abnormal, can also extend, alternatively, temporarily
Stop, alternatively, freezing the corresponding Claims Resolution operation of the drug protection amount settlement request.Wherein, Claims Resolution operation is that the reimbursement information is corresponding
Reimbursed sum transfer initiate the drug protection amount settlement request medical institutions account in.
Optionally, if the drug protection amount settlement request is not within the reimbursement time limit corresponding time, alternatively, the accumulative report
Pin is insured amount to be less than the reimbursement thresholding, then Claims Resolution operation is carried out according to normal process, by the corresponding reimbursement business of the reimbursement information
Data are transferred into the business datum account of the corresponding medical institutions of drug protection amount settlement request, i.e., the reimbursement information is corresponding
Reimbursed sum is transferred in the account for initiating the medical institutions of the drug protection amount settlement request.
In a further implementation, by the corresponding reimbursed sum of reimbursement information transfer initiate the drug protection amount clearing ask
After in the account of the medical institutions asked, this can be paid for protection amount and be revised as the accumulative reimbursement protection amount.
In the embodiment of the present invention, time when by the accumulative reimbursement protection amount to target medicine and settling accounts judges,
It can determine whether the accumulative compensation protection amount of the target medicine alreadys exceed the thresholding amount of reimbursement, and determine the time of clearing
Whether in using the validity period of drug given, when the accumulative compensation protection amount of target medicine be more than the thresholding amount of reimbursement simultaneously
And time of clearing when being in the validity period of drug given, illustrate that the reimbursement of this part may submit an expense account is the drug given
Expense, issuing reimbursement abnormal prompt can make the personnel for being responsible for Claims Resolution notice this abnormal conditions, so as to the situation
It is verified, prevents insurance fraud, it to a certain extent can be to avoid the additional Claims Resolution expenditure for increasing Medical Insurance Organizations.
In some possible scenes, in the reimbursement period longer situation of target medicine, when preset state, user makes
It when being finished the drug given, needs to continue drug purchase, the drug for continuing purchase can be submitted an expense account, and therefore, issue
After submitting an expense account abnormal prompt, the reimbursement abnormal prompt can be released after a certain time, to facilitate preset state user can be with
Continue to buy and normally submit an expense account.Referring to fig. 2, Fig. 2 is another determining drug reimbursement Information abnormity provided in an embodiment of the present invention
Method flow diagram, as shown in the figure, which comprises
S201, obtains the drug protection amount settlement request for being directed to target medicine, and the drug protection amount settlement request includes default
The corresponding reimbursement information of the identity information of status user, the target medicine and the weight information of the preset state user.
S202 determines the preset state user according to the identity information of the preset state user and the reimbursement information
The protection amount of compensation and accumulative reimbursement within the reimbursement period of the target medicine is insured amount, described to have paid for the insured amount and accumulative reimbursement
Protection amount is the corresponding protection amount of the target medicine.
S203, obtains the usage and dosage rule of the target medicine, and is used according to the weight information and the usage
Gauge then determines the corresponding single dosage of the preset state user.
S204 obtains the corresponding drug Huimin rule of the target medicine, and advises according to insured amount, described drug Huimin has been paid for
Then and the single dosage determines that the corresponding reimbursement thresholding of the target medicine, the reimbursement thresholding are greater than or equal to institute
It states and has paid for protection amount, the drug Huimin rule is to buy the quantity of the target medicine to reach preset paid drug period corresponding
Quantity after, giving quantity is that the target medicine of corresponding quantity of preset free drug period gives preset state user, drug
Period is for reflecting that user uses attainable treatment degree after drug.
S205, when determining the corresponding reimbursement of the target medicine according to the reimbursement thresholding and the drug Huimin rule
Limit, the reimbursement time limit are less than or equal to the reimbursement period.
S206, it is also, described accumulative if the drug protection amount settlement request is within the reimbursement time limit corresponding time
Reimbursement is insured amount to be greater than the reimbursement thresholding, it is determined that the drug protection amount settlement request has exception, issues reimbursement abnormal prompt.
Here, the specific implementation of step S201~S206 can refer to the description of step S101~S106, herein no longer
It repeats.
S207 determines the prompt of the reimbursement abnormal prompt according to the drug protection amount settlement request and the reimbursement time limit
Duration.
In the embodiment of the present invention, determine that the prompt of reimbursement abnormal prompt is held according to drug protection amount settlement request and reimbursement time limit
The mode of continuous duration are as follows: according between the initial time of time and the reimbursement period when getting the drug protection amount settlement request
Duration, the difference between the reimbursement time limit and the duration is determined into the prompt duration.
For example, the initial time in reimbursement period is 00:00:00 on January 1st, 2018, reimbursement time limit is 140 days, is got
The time of the drug protection amount settlement request is on 2 1st, 2018 00:00:00, it is determined that gets the drug protection amount settlement request
When time and the reimbursement period initial time between when it is 31 days a length of, it is determined that prompt duration be 140-31=
109 days.
S208 unlocks the reimbursement and mentions extremely after passing through the period that time span is the prompt duration
Show.
In the specific implementation, the reimbursement abnormity prompt can be released by modes such as removal abnormal marking, auditory tone cues.
In a further implementation, it can release and the corresponding Claims Resolution operation of drug protection amount settlement request is freezed, execute
The drug protection amount settlement request and the corresponding reimbursement information of the target medicine is settled accounts, i.e., it is the reimbursement information is corresponding
Reimbursed sum is transferred in the account for initiating the medical institutions of the drug protection amount settlement request.
In the embodiment of the present invention, determined drug protection amount settlement request there are exception and have issued reimbursement abnormal prompt it
Afterwards, it determines that reimbursement abnormal prompt needs lasting duration, is continuing to have prompted to contact the abnormal prompt after the duration, visually make
Obtain the available normal reimbursement of drug in normal Claims Resolution range.
In some possible embodiments, it in above-mentioned embodiment of the method shown in fig. 1 or fig. 2, can also determine
The corresponding maximum compensation amount of the target medicine in the reimbursement period；If the accumulative reimbursement is insured amount greater than the maximum compensation volume
Degree, then freeze or refuse the drug protection amount settlement request.
In one possible implementation, determining that maximum within the reimbursement period of target medicine compensates amount can be with are as follows:
Determine that maximum of the target medicine within the reimbursement period has according to usage and dosage rule, single dosage and drug Huimin rule
Repay Quantity of drugs；The corresponding drug total cost of target medicine that quantity is maximum paid Quantity of drugs is determined as the target medicine
Maximum compensation amount of the product within the reimbursement period.
Specifically, determine that target medicine is being reported according to usage and dosage rule, single dosage and drug Huimin rule
Sell the concrete mode of the paid Quantity of drugs of maximum in the period are as follows: determine at this according to usage and dosage rule and single dosage
Submit an expense account the corresponding drug total quantity of the target medicine in the period；According to the drug total quantity, the drug Huimin rule and the list
Secondary dosage determines the corresponding paid Quantity of drugs of maximum of the target medicine within the reimbursement period.
In the specific implementation, can determine the use time of the target medicine within the reimbursement period according to the usage and dosage rule
Number；The total quantity of the drug is determined according to the specification of the access times, the single dosage and the target medicine.
For example, the reimbursement period is 1 year, target medicine is injection infliximab, and target medicine is injection English husband
It is divided between the anti-use in sharp Xidan 0 week, 2 weeks, 6 weeks, in (6+8) week, (6+16 weeks) ..., (6+8n) was all, the Xidan injection Ying Fuli
Anti- single dosage is 250 milligrams, and the specification of injection infliximab is 100 milligrams/bottle, injection Ying Fulixi
The drug Huimin rule of monoclonal antibody is to buy three courses for the treatment of to send a course for the treatment of, and each course for the treatment of uses the drug 1 time, then according to usage and dosage
Rule, which determines, to be needed in 1 year using the injection infliximab to be 8 times, determines that maximum Quantity of drugs is 250*8/100=
20, Quantity of drugs is maximum with compensation
By determining that the amount of money corresponding to maximum Quantity of drugs with compensation and the drug by the quantity is determined as maximum compensation volume
Degree guarantees the available reimbursement of drug in normally Claims Resolution range under the premise of avoiding excessively submitting an expense account.
The method of inventive embodiments is described above, the device of inventive embodiments is described below.
It is a kind of composition knot of the device of determining drug reimbursement Information abnormity provided in an embodiment of the present invention referring to Fig. 3, Fig. 3
Structure schematic diagram, the device 30 include:
Request module 301, for obtaining the drug protection amount settlement request for being directed to target medicine, the drug protection amount knot
The identity information that request includes preset state user, the corresponding reimbursement information of the target medicine and the preset state is calculated to use
The weight information at family；
Protection amount compensate determining module 302, for according to the preset state user identity information and the reimbursement information
Determine that compensation protection amount and accumulative reimbursement of the preset state user within the reimbursement period of the target medicine are insured amount, it is described
Paying for insured amount is the corresponding protection amount of the target medicine with the accumulative reimbursement protection amount, in the corresponding period in reimbursement period
The accumulative reimbursement protection amount of the target medicine is not reset；
Dosage determining module 303, for obtaining the usage and dosage rule of the target medicine, and according to the weight
Information and the usage and dosage rule determine the corresponding single dosage of the preset state user；
Thresholding amount determining module 304, for obtaining the target medicine corresponding drug Huimin rule, and according to having paid for
The insured amount and described drug Huimin rule determines that the corresponding reimbursement thresholding of the target medicine, the reimbursement thresholding are greater than or equal to
Described to have paid for protection amount, the drug Huimin rule is to buy the quantity of the target medicine to reach the preset paid drug period pair
After the quantity answered, giving quantity is that the target medicine of corresponding quantity of preset free drug period gives preset state user, medicine
The product period is for reflecting that user uses attainable treatment degree after drug；
Reimbursement time limit determining module 305 for obtaining the usage and dosage rule of the target medicine, and has been paid for according to described
Insured amount, described usage and dosage rule and the drug Huimin rule determine the corresponding reimbursement time limit of the target medicine, the report
The time limit is sold less than or equal to the reimbursement period；
Abnormal determining module 306, if for the drug protection amount settlement request in the reimbursement time limit corresponding time
It is interior, also, the accumulative reimbursement is insured amount greater than the reimbursement thresholding, it is determined that and there is exception in the drug protection amount settlement request,
Issue reimbursement abnormal prompt.
In a kind of possible design, the dosage determining module 303 is specifically used for:
Determine in usage and dosage rule using weight as the unit dosage of medication unit；
The product of the corresponding weight of the weight information and the unit dosage is determined as the preset state user
Corresponding single dosage.
In a kind of possible design, the exception determining module 306 is also used to: if the drug protection amount settlement request
Not within the reimbursement time limit corresponding time, alternatively, the accumulative reimbursement is insured amount to be less than the reimbursement thresholding, then by the report
The corresponding reimbursement business datum of pin information is transferred to the business datum account of the corresponding medical institutions of the drug protection amount settlement request
In family.
In a kind of possible design, the thresholding amount determining module 304 is specifically used for:
The target medicine corresponding paid drug period is determined according to the drug Huimin rule；
The corresponding paid drug of the target medicine is determined according to the paid drug period and the single dosage
Quantity；
Determine that the first expense, first expense are the corresponding drug of target medicine that quantity is the paid Quantity of drugs
Total cost；
Insured amount the corresponding reimbursement thresholding of the target medicine, the target are determined with first expense according to described paid for
The corresponding reimbursement door of drug is limited to N times of the first expense, and N is the positive integer more than or equal to 1.
In a kind of possible design, the reimbursement time limit determining module 305 is specifically used for:
The target medicine corresponding paid drug period and free drug period are determined according to the drug Huimin rule；
Determine that the target medicine period is corresponding using duration, the target medicine period is that quantity is the paid drug week
The sum of phase and free drug period；
The corresponding reimbursement time limit of the target medicine, the reimbursement are determined according to the reimbursement thresholding and the use duration
When be limited to M times using duration, M is the positive integer more than or equal to 1.
In a kind of possible design, described device 30 further include:
Duration determining module 307, for determining institute according to the drug protection amount settlement request and the reimbursement time limit
State the prompt duration of reimbursement abnormal prompt；
Abnormal prompt release module 308, for by time span be it is described prompt duration period after,
Unlock the reimbursement abnormal prompt.
In a kind of possible design, described device 30 further include:
Maximum amount determining module 309, for determining the corresponding maximum compensation of the target medicine described within the reimbursement period
Pay amount；
Request refusal module 310, if being greater than the maximum compensation amount for the accumulative reimbursement to be insured amount, freeze or
Refuse the drug protection amount settlement request.
In a kind of possible design, the maximum amount determining module 309 is specifically used for:
It is determined according to the usage and dosage rule, single dosage and the drug Huimin rule in the reimbursement week
The corresponding paid Quantity of drugs of maximum of the target medicine in phase；
The corresponding drug total cost of target medicine that quantity is the maximum paid Quantity of drugs is determined as the target
Maximum compensation amount of the drug within the reimbursement period.
In a kind of possible design, the maximum amount determining module 309 is specifically used for:
The target medicine described within the reimbursement period is determined according to the single dosage and the usage and dosage rule
The corresponding drug total quantity of product；
The target medicine within the reimbursement period is determined according to the drug total quantity and the drug Huimin rule
The corresponding paid Quantity of drugs of maximum.
It should be noted that unmentioned content can be found in the description of embodiment of the method in the corresponding embodiment of Fig. 3, here
It repeats no more.
In the embodiment of the present invention, determine that the device of drug reimbursement Information abnormity is insured amount by the accumulative reimbursement to target medicine
And reimbursement time limit when clearing is judged, can determine whether the accumulative compensation protection amount of the target medicine alreadys exceed reimbursement
Thresholding amount, and determine whether the time of clearing is in using in the validity period of drug given, it is tired when target medicine
Meter compensates protection amount more than the thresholding amount submitted an expense account and when the time of clearing is in the validity period for the drug given, and illustrates this portion
Point reimbursement may submit an expense account be the drug given expense, issue reimbursement abnormal prompt can make be responsible for Claims Resolution personnel notice
This abnormal conditions prevent insurance fraud so as to verify the situation, can increase doctor to a certain extent to avoid additional
Treat the Claims Resolution expenditure of insurance institution.
Referring to fig. 4, Fig. 4 is the composition of another device for determining drug reimbursement Information abnormity provided in an embodiment of the present invention
Structural schematic diagram, the device 40 include processor 401, memory 402 and communication interface 403.Processor 401 is connected to storage
Device 402 and communication interface 403, such as processor 401 can be connected to memory 402 and communication interface 403 by bus.
Processor 401 is configured as that the device of the determining drug reimbursement Information abnormity is supported to execute described in Fig. 1 or Fig. 2
Determine corresponding function in the method for drug reimbursement Information abnormity.The processor 401 can be central processing unit (central
Processing unit, CPU), network processing unit (network processor, NP), hardware chip or any combination thereof.
Above-mentioned hardware chip can be specific integrated circuit (application specific integrated circuit, ASIC),
Programmable logic device (programmable logic device, PLD) or combinations thereof.Above-mentioned PLD can be complex programmable
Logical device (complex programmable logic device, CPLD), field programmable gate array (field-
Programmable gate array, FPGA), Universal Array Logic (generic array logic, GAL) or its any group
It closes.
402 memory of memory is for storing program code etc..Memory 402 may include volatile memory
(volatile memory, VM), such as random access memory (random access memory, RAM)；Memory 402
It may include nonvolatile memory (non-volatile memory, NVM), such as read-only memory (read-only
Memory, ROM), flash memory (flash memory), hard disk (hard disk drive, HDD) or solid state hard disk
(solid-state drive, SSD)；Memory 402 can also include the combination of the memory of mentioned kind.The present invention is implemented
In example, memory 402 is used to store the usage and dosage rule of target medicine, and the corresponding drug Huimin rule of target medicine has been paid for
Protection amount etc..
The communication interface 403 is for sending or receiving data.
Processor 401 can call said program code to execute following operation:
The drug protection amount settlement request for being directed to target medicine is obtained by communication interface 403, the drug protection amount clearing are asked
Ask the corresponding reimbursement information of identity information including preset state user, the target medicine and the preset state user
Weight information；
Determine the preset state user in institute according to the identity information of the preset state user and the reimbursement information
It states the protection amount of compensation in the reimbursement period of target medicine and adds up reimbursement protection amount, it is described to have paid for the insured amount and described accumulative reimbursement protection amount
It is the corresponding protection amount of the target medicine, the accumulative reimbursement for submitting an expense account the target medicine in the corresponding period in period is protected
Volume is not reset；
The usage and dosage rule of the target medicine is obtained, and according to the weight information and usage and dosage rule
Determine the corresponding single dosage of the preset state user；
Obtain the target medicine corresponding drug Huimin rule, and according to paid for insured amount, described drug Huimin rule with
And the single dosage determines the corresponding reimbursement thresholding of the target medicine, the reimbursement thresholding be greater than or equal to it is described
Pay for insured amount, the drug Huimin rule is to buy the quantity of the target medicine to reach corresponding number of preset paid drug period
After amount, giving quantity is that the target medicine of corresponding quantity of preset free drug period gives preset state user, drug period
For reflecting that user uses attainable treatment degree after drug；
The corresponding reimbursement time limit of the target medicine is determined according to the reimbursement thresholding and the drug Huimin rule, it is described
Reimbursement time limit is less than or equal to the reimbursement period；
If the drug protection amount settlement request is within the reimbursement time limit corresponding time, also, the accumulative reimbursement
Protection amount is greater than the reimbursement thresholding, it is determined that the drug protection amount settlement request has abnormal, sending reimbursement abnormal prompt.
It should be noted that the realization of each operation can also correspond to referring to Fig.1 or the phase of embodiment of the method shown in Fig. 2
It should describe；The processor 401 can also cooperate other operations executed in above method embodiment with communication interface 403.
The embodiment of the present invention also provides a kind of computer storage medium, and the computer storage medium is stored with computer journey
Sequence, the computer program include program instruction, and described program instruction executes the computer such as
Method described in previous embodiment, the computer can be the one of the device of determination drug reimbursement Information abnormity mentioned above
Part.For example, above-mentioned processor 401.
Those of ordinary skill in the art will appreciate that realizing all or part of the process in above-described embodiment method, being can be with
Relevant hardware is instructed to complete by computer program, the program can be stored in a computer-readable storage medium
In, the program is when being executed, it may include such as the process of the embodiment of above-mentioned each method.Wherein, the storage medium can be magnetic
Dish, CD, read-only memory (Read-Only Memory, ROM) or random access memory (Random Access
Memory, RAM) etc..
The above disclosure is only the preferred embodiments of the present invention, cannot limit the right model of the present invention with this certainly
It encloses, therefore equivalent changes made in accordance with the claims of the present invention, is still within the scope of the present invention.
Claims (10)
1. a kind of method of determining drug reimbursement Information abnormity characterized by comprising
The drug protection amount settlement request for being directed to target medicine is obtained, the drug protection amount settlement request includes preset state user
The corresponding reimbursement information of identity information, the target medicine and the weight information of the preset state user；
Determine the preset state user in the mesh according to the identity information of the preset state user and the reimbursement information
The protection amount of compensation submitted an expense account in the period and the accumulative reimbursement for marking drug are insured amount, and protection amount and the accumulative reimbursement protection amount of having paid for is
The corresponding protection amount of the target medicine, the accumulative reimbursement protection amount of the target medicine is not in the corresponding period in reimbursement period
It resets；
The usage and dosage rule of the target medicine is obtained, and is determined according to the weight information and the usage and dosage rule
The corresponding single dosage of the preset state user；
Obtain the target medicine corresponding drug Huimin rule, and according to having paid for insured amount, the described drug Huimin rule and institute
It states single dosage and determines that the corresponding reimbursement thresholding of the target medicine, the reimbursement thresholding have paid for guarantor more than or equal to described
Volume, the drug Huimin rule are to buy the quantity of the target medicine to reach corresponding quantity of preset paid drug period
Afterwards, it gives the target medicine that quantity is corresponding quantity of preset free drug period and gives preset state user, the drug period is used
Attainable treatment degree after drug is used in reflection user；
The corresponding reimbursement time limit of the target medicine, the reimbursement are determined according to the reimbursement thresholding and the drug Huimin rule
Time limit is less than or equal to the reimbursement period；
If the drug protection amount settlement request is within the reimbursement time limit corresponding time, also, the accumulative reimbursement is insured amount
Greater than the reimbursement thresholding, it is determined that the drug protection amount settlement request has abnormal, sending reimbursement abnormal prompt.
2. the method according to claim 1, wherein described according to the weight information and the usage and dosage
Rule determines the corresponding single dosage of the preset state user, comprising:
Determine in usage and dosage rule using weight as the unit dosage of medication unit；
It is corresponding that the corresponding weight of the weight information with the product of the unit dosage is determined as the preset state user
Single dosage.
3. the method according to claim 1, wherein the method also includes:
If the drug protection amount settlement request is not within the reimbursement time limit corresponding time, alternatively, the accumulative reimbursement is protected
Volume is less than or equal to the reimbursement thresholding, then transfers the corresponding reimbursement business datum of the reimbursement information insured amount to the drug
In the business datum account of the corresponding medical institutions of settlement request.
4. method according to claim 1-3, which is characterized in that also wrapped after the sending reimbursement abnormal prompt
It includes:
The prompt duration of the reimbursement abnormal prompt is determined according to the drug protection amount settlement request and the reimbursement time limit；
After passing through the period that time span is the prompt duration, the reimbursement abnormal prompt is unlocked.
5. method according to claim 1-3, which is characterized in that the method also includes:
Determine the corresponding maximum compensation amount of the target medicine described within the reimbursement period；
If the accumulative reimbursement is insured amount to be greater than the maximum compensation amount, freezes or refuse the drug protection amount clearing and ask
It asks.
6. according to the method described in claim 5, it is characterized in that, determination target medicine within the reimbursement period
Corresponding maximum compensates amount
It is determined within the reimbursement period according to the usage and dosage rule, single dosage and the drug Huimin rule
The corresponding paid Quantity of drugs of maximum of the target medicine；
The corresponding drug total cost of target medicine that quantity is the maximum paid Quantity of drugs is determined as the target medicine
Maximum compensation amount within the reimbursement period.
7. according to the method described in claim 6, it is characterized in that, described according to the usage and dosage rule, single medicament
Amount and the drug Huimin rule determine the corresponding paid Quantity of drugs of maximum of the target medicine described within the reimbursement period
Include:
The target medicine pair within the reimbursement period is determined according to the single dosage and the usage and dosage rule
The drug total quantity answered；
Determine that the target medicine is corresponding within the reimbursement period according to the drug total quantity and the drug Huimin rule
The paid Quantity of drugs of maximum.
8. a kind of device of determining drug reimbursement Information abnormity characterized by comprising
Request module, for obtaining the drug protection amount settlement request for being directed to target medicine, the drug protection amount settlement request
The body of the corresponding reimbursement information of identity information, the target medicine including preset state user and the preset state user
Weight information；
Protection amount compensates determining module, for according to the identity information of the preset state user and reimbursement information determination
Compensation protection amount and accumulative reimbursement of the preset state user within the reimbursement period of the target medicine are insured amount, it is described paid for it is insured amount and
The accumulative reimbursement protection amount is the corresponding protection amount of the target medicine, the target in the corresponding period in reimbursement period
The accumulative reimbursement protection amount of drug is not reset；
Dosage determining module, for obtain the target medicine usage and dosage rule, and according to the weight information with
And the usage and dosage rule determines the corresponding single dosage of the preset state user；
Thresholding amount determining module, for obtaining the target medicine corresponding drug Huimin rule, and according to having paid for insured amount, institute
It states drug Huimin rule and the single dosage determines the corresponding reimbursement thresholding of the target medicine, the reimbursement thresholding
Protection amount has been paid for more than or equal to described, and the drug Huimin rule is to buy the quantity of the target medicine to reach preset paid
After drug period corresponding quantity, target medicine that quantity is corresponding quantity of preset free drug period is given to default shape
State user, the drug period is for reflecting that user uses attainable treatment degree after drug；
Reimbursement time limit determining module, for determining the target medicine pair according to the reimbursement thresholding and the drug Huimin rule
The reimbursement time limit answered, the reimbursement time limit are less than or equal to the reimbursement period；
Abnormal determining module, if for the drug protection amount settlement request within the reimbursement time limit corresponding time, also,
The accumulative reimbursement is insured amount to be greater than the reimbursement thresholding, it is determined that the drug protection amount settlement request has abnormal, sending reimbursement
Abnormal prompt.
9. a kind of device of determining drug reimbursement Information abnormity, including processor, memory and communication interface, the processing
Device, memory and communication interface are connected with each other, wherein the communication interface is used for transmission data, and the memory is for storing
Program code, the processor execute the method according to claim 1 to 7 for calling said program code.
10. a kind of computer storage medium, which is characterized in that the computer storage medium is stored with computer program, described
Computer program includes program instruction, and described program instruction makes the processor execute such as claim when being executed by a processor
The described in any item methods of 1-7.
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| CN109523398A (en) * | 2018-10-27 | 2019-03-26 | 平安医疗健康管理股份有限公司 | The method and apparatus of drug reimbursement Information abnormity |
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