WO2019041804A1 - Personalized checking method and apparatus for claim settlement orders, storage medium, and terminal - Google Patents

Abstract

The present application is applicable to the technical field of communications, and provides a personalized checking method and apparatus for claim settlement orders, a storage medium, and a terminal. The method comprises: obtaining a checking rule configured by an institution administrator in a checking rule configuration interface, and associating the checking rule with an institution code corresponding to the institution administrator; starting a checking process of claim settlement orders when an automatic checking instruction is received, to obtain claim settlement orders to be checked and an institution code of an accepting institution thereof; automatic checking the claim settlement orders to be checked according to the checking rule associated with the institution code, to obtain claim settlement orders not meeting the checking rule and detail information thereof; and distributing the claim settlement orders not meeting the checking rule and the detail information thereof to corresponding accepting institutions for manual checking. The present application resolves the problems of the disability of the existing automatic checking rules to be fully applicable to all institutions, and low degree of automation for claim settlement order checking.

Description

Personalized review method, device, storage medium and terminal for claim order

This application is based on the Chinese invention patent application filed on August 28, 2017, with the application number of 201710748109.7, entitled "Personalized Review Method, Device, Storage Medium and Terminal for Claims Order", and requires its priority.

Technical field

The present application belongs to the field of communication technologies, and in particular, to a personalized verification method, device, storage medium and terminal for a claim order.

Background technique

With the development of Internet technology, the insurance claims section is changing now. More and more insurance companies use automated auditing methods to review and verify claims orders to improve the efficiency of insurance claims. The automatic review rules for existing claim orders are completed by the headquarters configuration and then used nationwide. The claim system matches the attributes of the insurance policy of the customer according to the risk attribute of the claim order, and then draws the audit conclusion according to the automatic audit rules. However, because the threshold of automatic audit rules configured at the headquarters is too high, the automated audit rules cannot be fully applied to all insurance institutions. For some insurance institutions, the compensation rate may be lowered due to the high threshold, resulting in customer churn and camp. With a reduction in receipts, there may be a large number of orders that need to be transferred to manual review, and the automation of insurance order reviews is low.

Summary of the invention

The embodiment of the present application provides a personalized auditing method, device, storage medium and terminal for a claim order, so as to solve the problem that the existing automated auditing rule cannot be fully applied to all organizations and the claiming order is less automated.

In a first aspect, a personalized review method for a claim order, the review method includes:

Obtaining an auditing rule configured by the organization administrator in the auditing rule configuration interface, and correlating the auditing rule with an organization code corresponding to the organization administrator;

When receiving the automatic audit instruction, the approval process of the claim order is started, and the claim code of the claim and the institution code of the accepting institution are obtained;

Performing an automated audit of the claim order to be audited according to the audit rule associated with the institution code, and obtaining a claim order and its detailed information that does not meet the audit rule;

The claim order and its detailed information that do not meet the audit rules are distributed to the corresponding receiving institution for manual review.

Further, before the obtaining an auditing rule configured by the organization administrator in the auditing rule configuration interface, the auditing method further includes:

Obtaining the account information of the requester when receiving the configuration instruction of the audit rule;

The account information is matched with an administrator account, and if the account information is an administrator account, the audit rule configuration interface is displayed.

Further, after the claim order and the detailed information that does not meet the audit rule are distributed to the corresponding receiving institution for manual review, the method further includes:

Start the monitoring thread according to the preset time;

Reading, by the monitoring thread, a preset SQL statement, querying the database according to the SQL statement, and obtaining the claim code of the settlement order and the institution code of the receiving institution that was closed the previous day;

Sending the claim order to the corresponding receiving institution according to the agency code, so that the receiving institution performs risk analysis on the audit rule configured by the receiving institution;

Wherein, the claim order includes a claim order through automatic review and a claim order through manual review.

Further, the configured audit rules include one or any combination of the following:

The adjustment order of the configuration claim order is the first accident after the disease, the disease after the accident or the most favorable to the customer;

The compensation amount is configured, and the compensation amount is a judgment criterion for determining a claim settlement to manual review based on the compensation amount;

The number of risk days is configured, and the number of risk days is a judgment criterion for determining a claim settlement to manual review based on the effective date of the commitment;

A risk disease is configured, which is a criterion for determining a claim-to-manual review based on the type of disease.

Further, the automatically reviewing the claim order to be audited according to the audit rule associated with the organization code includes:

Traversing each claim order to be reviewed, comparing the amount of the claim to be reviewed and the claim amount;

Verifying whether the number of days of effective coverage of the claims to be reviewed is within the range of risk days;

Matching the type of disease to which the claim order to be reviewed belongs and the risky disease.

In a second aspect, a personalized review device for a claim order, the review device includes:

The association module is configured to obtain an audit rule configured by the organization administrator in the audit rule configuration interface, and associate the audit rule with an organization code corresponding to the organization administrator;

The obtaining module is configured to start an auditing process of the claim order when receiving the automatic auditing instruction, and obtain the institution code of the claim order to be audited and the receiving institution;

An auditing module, configured to automatically review the claim order to be audited according to the auditing rule associated with the institution code, and obtain a claim order and detailed information that does not meet the auditing rule;

The distribution module is configured to distribute the claim order and the detailed information that does not meet the audit rule to the corresponding receiving institution for manual review.

Further, the review apparatus further includes:

The verification module is configured to: when receiving the configuration instruction of the audit rule, obtain the account information of the requester; match the account information with the administrator account, and display the audit rule if the account information is an administrator account Configuration interface.

Further, the review apparatus further includes:

The monitoring module is configured to start the monitoring thread according to the preset time; read the preset SQL statement by the monitoring thread, query the database according to the SQL statement, and obtain the claim code of the settlement order and the receiving institution of the previous day; The mechanism code sends the claim order to a corresponding accepting institution, so that the accepting institution performs risk analysis on the audit rule configured by the receiving institution;

Wherein, the claim order includes a claim order through automatic review and a claim order through manual review.

A third aspect, one or more non-volatile readable storage media storing computer readable instructions, when executed by one or more processors, causing said one or more processors to execute The following steps:

Obtaining an auditing rule configured by the organization administrator in the auditing rule configuration interface, and correlating the auditing rule with an organization code corresponding to the organization administrator;

When receiving the automatic audit instruction, the approval process of the claim order is started, and the claim code of the claim and the institution code of the accepting institution are obtained;

Performing an automated audit of the claim order to be audited according to the audit rule associated with the institution code, and obtaining a claim order and its detailed information that does not meet the audit rule;

The claim order and its detailed information that do not meet the audit rules are distributed to the corresponding receiving institution for manual review.

In a fourth aspect, the embodiment of the present application further provides a terminal, including a memory, a processor, and computer readable instructions stored on the memory and executable on the processor, when the processor executes the computer readable instruction Implement the following steps:

Obtaining an auditing rule configured by the organization administrator in the auditing rule configuration interface, and correlating the auditing rule with an organization code corresponding to the organization administrator;

When receiving the automatic audit instruction, the approval process of the claim order is started, and the claim code of the claim and the institution code of the accepting institution are obtained;

Performing an automated audit of the claim order to be audited according to the audit rule associated with the institution code, and obtaining a claim order and its detailed information that does not meet the audit rule;

The claim order and its detailed information that do not meet the audit rules are distributed to the corresponding receiving institution for manual review.

Details of one or more embodiments of the present application are set forth in the accompanying drawings and description below. Other features and advantages of the present invention will be apparent from the description, drawings and claims.

DRAWINGS

In order to more clearly illustrate the embodiments of the present application or the technical solutions in the prior art, the drawings to be used in the embodiments or the prior art description will be briefly described below. Obviously, the drawings in the following description are only It is a certain embodiment of the present application, and other drawings can be obtained according to the drawings without any creative work for those skilled in the art.

1 is a first implementation flowchart of a personalized verification method for a claim order provided by an embodiment of the present application;

2 is a second implementation flowchart of a personalized review method for a claim order provided by an embodiment of the present application;

3 is a third implementation flowchart of a personalized verification method for a claim order provided by an embodiment of the present application;

4 is a structural diagram of a component of a personalized review apparatus for claim orders provided by an embodiment of the present application;

FIG. 5 is a schematic diagram of a terminal provided by an embodiment of the present application.

Detailed ways

In order to make the objects, technical solutions, and advantages of the present application more comprehensible, the present application will be further described in detail below with reference to the accompanying drawings and embodiments. It is understood that the specific embodiments described herein are merely illustrative of the application and are not intended to be limiting.

In the prior art, the claim orders of the various insurance institutions are automatically audited according to the nationally-used automatic audit rules set by the headquarters. This situation is likely to result in an excessively high requirement for the automatic audit rules set by the headquarters. The problem of the insurance institution, which leads to the loss rate of the claims of the insurance institution and the loss of customers; there may also be a large number of orders that need to be transferred to the manual review, which also reduces the automation of the claims order review. In view of this, the embodiment of the present application improves the setting manner of the automatic auditing rule, which is set by the original headquarters only and improved to the administrator setting of each institution, and provides an auditing rule configuration interface to each organization administrator. The organization administrator can configure personalized audit rules for the organization and develop automated audit rules that apply to the organization. FIG. 1 shows a first implementation flow of a personalized review method for a claim order provided by an embodiment of the present application. In the embodiment of the present application, the claim order is a medical insurance order. The embodiment of the present application describes the audit processing process from the perspective of a backend server of the claims system, including but not limited to a computer and a server. Referring to FIG. 1, the personalized review method of the claim order includes:

In step S101, an auditing rule configured by the organization administrator in the auditing rule configuration interface is acquired, and the auditing authority is associated with the organization code corresponding to the organization administrator.

Here, the embodiment of the present application adds a menu for each organization administrator on the original claim system, that is, the audit rule configuration interface. The organization administrator is a user corresponding to each organization that can view the audit rule configuration interface. The embodiment of the present application sets only the organization administrator to have the viewing authority, and hides the audit rule setting interface from other users. An organization administrator with viewing rights can view and operate the audit rule settings interface.

The organization administrator can log in to the claim system in the front-end device, enter the audit rule configuration interface through the navigation identifier, and configure an audit rule applicable to the needs of the organization on the audit rule configuration interface according to the requirements of the organization. When receiving the confirmation instruction input by the organization administrator on the configuration interface, the backend server acquires an audit rule configured by the organization administrator on the configuration interface, and an organization code corresponding to the organization administrator, and associates The audit rule is an organization code corresponding to the organization administrator. The audit rules associated with the agency code apply only to claim orders accepted by the institution. The mechanism is encoded as a unique identifier of the receiving authority on the claims system.

Optionally, the claim order is a medical insurance order. As a preferred example of the present application, the configured audit rule may include one or a combination of the following:

The adjustment order of the configuration claim order is the first accident after the disease, the disease after the accident or the most favorable to the customer;

The compensation amount is configured, and the compensation amount is a judgment criterion for determining a claim settlement to manual review based on the compensation amount;

The number of risk days is configured, and the number of risk days is a judgment criterion for determining a claim settlement to manual review based on the effective date of the commitment;

A risk disease is configured, which is a criterion for determining a claim-to-manual review based on the type of disease.

Wherein, the adjustment order is a process in which the claim system calculates the multi-line claim order and gives a claim conclusion.

The claim amount is determined by the agency administrator based on the claims data of the previous month, the previous quarter or the first half of the year, combined with the maximum payout limit of the automatic audit demand forecast. Different institutions generally correspond to different claims.

The risk days are preset time ranges calculated from the insured date, and are used to avoid intentional insurance and insurance fraud.

The risky disease is a type of underwriting disease that requires on-site investigation and evidence collection, and is related to different administrative divisions and economic development levels. For the configuration of risky diseases, a record table can be added to the database to record the type of disease selected by the institution administrator.

In the embodiment of the present application, different organization codes can be associated with different automatic audit rules and rule details, thereby realizing the automatic review rules of the organization personalized configuration, so that the claim orders of different organizations can be automatically audited as needed, and solved. The automated audit rules for existing headquarters configurations are not fully applicable to all agency issues.

In step S102, when the automatic auditing instruction is received, the review process of the claim order is started, and the claim code of the claim and the institution code of the accepting institution are obtained.

In the embodiment of the present application, the automatic auditing instruction is triggered by the organization personnel on the front-end device, and is sent by the front-end device to generate a request message to the back-end server. The request message includes an automatic auditing instruction and an organization code. After receiving the request message sent by the front-end device, the back-end server parses the request message to obtain an automatic auditing instruction and an organization code, and then starts an auditing process according to the automatic auditing instruction, and queries and obtains the pending review from the oracle database in the background of the claims system. Claim order.

In step S103, the claim order to be audited is automatically audited according to the audit rule associated with the organization code, and the claim order and its detailed information that do not meet the audit rule are obtained.

After obtaining the claim order to be reviewed, the embodiment of the present application queries the associated audit rule according to the agency code. The claim order is screened by using the audit rule, specifically, traversing each claim order to be audited, and determining whether the attribute information of the claim order does not meet the audit rule associated with the institution code; if yes, Obtain the order number of the pending order and its detailed information.

Optionally, as previously described, the configured audit rules include configuring the amount of claims, risk days, and risky diseases that need to be transferred to manual review. Correspondingly, the automatic review of the claim order to be audited according to the audit rule associated with the agency code in step S103 includes:

Traversing each claim order to be reviewed, comparing the amount of the claim to be reviewed and the claim amount;

Verifying whether the number of days of effective coverage of the claims to be reviewed is within the range of risk days;

Matching the type of disease to which the claim order to be reviewed belongs and the risky disease.

Here, for the claim amount, when the claim amount of the claim order is greater than the claim amount, it indicates that the claim order has exceeded the maximum compensation limit predicted by the organization, and needs to be manually reviewed; when the claim amount is less than or equal to the claim amount When the amount is paid, it indicates that the claim order can be automatically reviewed within the maximum compensation limit predicted by the organization. In the embodiment of the present application, the compensation amount is set by the organization administrator, so that the organization can dynamically set the payment amount according to requirements. If it is necessary to improve the automation degree of the claim order review, the agency's compensation amount can be set higher than the national unified compensation amount. If it is necessary to increase the risk supervision of the claim order, the institution's compensation amount can be set lower than the national unified compensation amount.

For the number of risk days, because the types of orders accepted by different insurance institutions are different, the number of risk days for the insurance to take effect is also different. In the embodiment of the present application, the number of risk days is set by the organization administrator to filter the claim orders whose number of days of the insured effective date is less than the risk days, and the potential risk claim orders are converted into manual audits, so that different organizations can The types of orders accepted are implemented to avoid the scam.

For the risky disease, the disease type to which the claim order to be reviewed belongs is matched with the record table in the database for each audit, and if the match is made, the claim order is marked, filtered, and converted into labor. Review, so that different agencies can implement the payment operation and reduce the risk of payment for the type of orders accepted.

Optionally, the detailed information of the claim order includes, but is not limited to, the date of the insurance claim, the risk person, the place of the insurance, the reason for the risk, and the like, so as to facilitate the review and view by the organization personnel.

Here, if the auditing rule associated with the institution code is fully met, it indicates that the claim order has passed the automatic review process; if one or more audit rules associated with the institution code are not met, it indicates that the claim order is not Pass the automated review process. For a claim order that does not pass the automatic review process, the embodiment of the present application flows it to a manual review state on a workflow. Alternatively, a flag may be added to distinguish a claim case that fails the automatic review process. .

In step S104, the claim order and the detailed information that do not meet the audit rule are distributed to the corresponding accepting institution for manual review.

Here, the case transfer of the claim order on the claims system is implemented by means of a workflow. A workflow is a type of business process that can be fully or partially automated, and can be passed and executed between different actors based on a set of process rules, documents, information or tasks. The workflow of the claim order can control the process direction of the claim order and the processing person. For the claim order that does not meet the audit rule, the embodiment of the present application pushes the workflow of the claim order to the acceptance according to the receiving institution. The organization's audit post is used for manual review. Optionally, the push of the claim order may be completed by sending a reminder email to the audit post or adding a task item to the claim system.

In summary, the embodiment of the present application automatically audits the claim order of the institution based on the auditing rules associated with the organization code, and solves the problem that the existing automated auditing rules cannot be fully applied to all organizations, and is beneficial to reducing the number of manual audits. The number of claims orders increases the automation of claims order review.

Optionally, as described above, the embodiment of the present application sets only the organization administrator to have the viewing authority, and hides the audit rule setting interface from other users. An organization administrator with viewing rights can view and operate the audit rule settings interface. In the prior art, when the organization administrator authenticates the user account when logging in to the claim system, the organization administrator can directly log in to the audit rule configuration interface, but in this case, the other person will be malicious after logging in to the claim system by the organization administrator. The risk of tampering. In order to solve the above problem, on the basis of the first implementation process of the personalized review method of the claim order provided in FIG. 1 , the second implementation process of the personalized review method of the claim order provided by the embodiment of the present application is proposed, as shown in FIG. 2 . Show.

In FIG. 2, before the obtaining the auditing rules configured by the organization administrator on the auditing rule interface in step S101 shown in FIG. 1, the personalized auditing method of the claim order includes:

In step S201, when the configuration instruction of the audit rule is received, the account information of the requester is acquired.

Here, the account information includes an account name and a password. As described above, the organization administrator can log in to the claims system at the front end device and then enter the audit rule configuration interface through the navigation identifier. Optionally, the navigation identifier includes a function option of the audit rule configuration. When the organization administrator triggers the function option of the audit rule configuration in a preset manner, the front-end device generates a request message according to the trigger operation, and The request message is sent to the backend server, and the backend server returns a DOM file to the front end device according to the request message, so that the front end device renders the account name and password input interface after requesting the DOM file to request The current organization administrator performs permission authentication.

If the organization administrator enters the account name and password as required, the front-end device sends the account name and password as the account information of the organization administrator to the back-end server. The backend server obtains the account name entered by the front page through String name=(String)req.getParameter("uname"), and then obtains the password entered by the front page through String password=(String)req.getParameter("upassword").

In step S202, the account information is matched with an administrator account, and if the account information is an administrator account, the audit rule configuration interface is displayed.

In the embodiment of the present application, the backend server establishes a login table in the SQL database through java. The login table maintains the administrator account information with the operation authority of the audit rule configuration interface, including the account name and password information. These administrator account information is stored in the form of an asc code. After obtaining the account information, the back-end server converts the account information into an asc code, and matches the administrator account in the login table one by one. If the account information matches any of the administrator accounts in the login table, it indicates that the current administrator has the authority to operate the audit rule configuration interface, and displays the audit rule configuration interface; otherwise, the account information and login If the administrator accounts in the table do not match, it indicates that the current administrator does not have the authority to operate the audit rule configuration interface, and displays the audit rule configuration interface.

The embodiment of the present application implements the secondary authority authentication of the requester configured by the auditing rule, and the secondary authority authentication is performed after the mechanism administrator triggers the function option of the auditing rule configuration, thereby further improving the security of configuring the personalized auditing rule. Sex.

Optionally, as described above, the embodiment of the present application implements an auditing rule applicable to the organization by the organization administrator on the audit rule configuration interface, and implements an automated audit of the organization as needed. However, these audit rules are configured by the organization administrator according to the organization's revenue status. Before the configuration, the organization administrator can only predict the audit results, and cannot conduct risk supervision on the audit rules. In order to solve the above problem, on the basis of the first implementation process of the personalized review method of the claim order provided in FIG. 1 , the third implementation process of the personalized review method of the claim order provided by the embodiment of the present application is proposed, as shown in FIG. 3 . Show.

After the claim order and the detailed information that does not meet the audit rule are distributed to the corresponding receiving institution for manual review, the personalized review method of the claim order further includes:

In step S301, the monitoring thread is started according to a preset time.

Here, the monitoring thread is used to filter the claim settlements that have been reviewed and closed for risk management and control. The preset time may be a specified time point, such as 8 am every day or 6 pm every day, to start the monitoring thread. Optionally, the preset time can be set by using a SQL server proxy new job.

In step S302, the monitoring thread reads the preset SQL statement, queries the database according to the SQL statement, and obtains the claim code of the settlement order and the institution code of the receiving institution that was closed the previous day.

Among them, the claim order that was closed the previous day includes the claim order through automatic review and the claim order through manual review. The embodiment of the present application further configures a database query statement for querying the closing order of the previous day from the database, that is, the SQL statement. After the monitoring thread starts, the SQL statement is read to obtain the query condition and the table name. In the embodiment of the present application, the query condition includes, but is not limited to, a closed case, a date of the previous day, an accepting institution, and the like. Then, the monitoring thread queries the database every one minute, obtains the table information corresponding to the table name specified by the SQL statement from the database, and obtains the claim order and the institution of the receiving institution that meet the query condition from the table information. Coding to obtain the claim code for the settlement of the previous day and the agency code of the receiving institution.

In step S303, the closing order is sent to the corresponding receiving institution according to the mechanism code, so that the receiving institution performs risk analysis on the auditing rules configured by the receiving institution.

After obtaining the claim order and its organization code, the monitoring thread sends the claim case to the corresponding accepting institution, thereby realizing the distribution of the branch, so that each institution can review the configuration based on the closed claim order. Rules analysis and risk management are beneficial to each organization to optimize its personalized review rules.

It should be understood that, in the foregoing embodiments, the size of the serial number of each step does not mean the order of execution order, and the order of execution of each step should be determined by its function and internal logic, and should not constitute any implementation process of the embodiment of the present application. limited.

It should be noted that those skilled in the art can understand that all or part of the steps of implementing the above embodiments may be completed by hardware, or may be instructed by computer readable instructions, and the computer readable instructions may be stored. In a non-volatile readable storage medium, the storage medium may be a read only memory, a magnetic disk or an optical disk, or the like.

FIG. 4 is a structural diagram showing the composition of the personalization review apparatus of the claim order provided by the embodiment of the present application. For the convenience of description, only the parts related to the embodiment of the present application are shown.

In the embodiment of the present application, the personalized review device of the claim order is used to implement the personalized review method of the claim order described in the foregoing embodiments of FIG. 1 to FIG. 3, which may be a software unit and a hardware unit built in the terminal. Or a combination of hardware and software. The terminal is a backend server in the claims system, including but not limited to a computer and a server.

Referring to FIG. 4, the personalized review device of the claim order includes:

The association module 41 is configured to acquire an audit rule configured by the organization administrator in the audit rule configuration interface, and associate the audit rule with an organization code corresponding to the organization administrator;

The obtaining module 42 is configured to: when receiving the automatic auditing instruction, initiate an auditing process of the claim order, and obtain the institution code of the claim order to be audited and the receiving institution;

The auditing module 43 is configured to perform an automatic audit on the claim order to be audited according to the auditing rule associated with the institution code, and obtain a claim order and its detailed information that does not meet the auditing rule;

The distribution module 44 is configured to distribute the claim order and the detailed information that does not meet the audit rule to the corresponding receiving institution for manual review.

Optionally, the review apparatus further includes:

The verification module 45 is configured to obtain the account information of the requester when receiving the configuration instruction of the audit rule before acquiring the audit rule configured by the organization administrator in the audit rule configuration interface; and performing the account information and the administrator account Matching, if the account information is an administrator account, the audit rule configuration interface is displayed.

Optionally, the review apparatus further includes:

The monitoring module 46 is configured to start the monitoring thread according to the preset time; read the preset SQL statement by the monitoring thread, query the database according to the SQL statement, and obtain the claim code of the settlement order and the institution code of the receiving institution that was closed the previous day; Sending the claim order to the corresponding receiving institution according to the agency code, so that the receiving institution performs risk analysis on the audit rule configured by the receiving institution;

Wherein, the claim order includes a claim order through automatic review and a claim order through manual review.

As a preferred example of the present application, the configured audit rules include one or any combination of the following:

The adjustment order of the configuration claim order is the first accident after the disease, the disease after the accident or the most favorable to the customer;

The compensation amount is configured, and the compensation amount is a judgment criterion for determining a claim settlement to manual review based on the compensation amount;

The number of risk days is configured, and the number of risk days is a judgment criterion for determining a claim settlement to manual review based on the effective date of the commitment;

A risk disease is configured, which is a criterion for determining a claim-to-manual review based on the type of disease.

Correspondingly, the auditing module 43 automatically audits the claim order to be audited according to the auditing rule associated with the organization code, including:

Traversing each claim order to be reviewed, comparing the amount of the claim to be reviewed and the claim amount;

Verifying whether the number of days of effective coverage of the claims to be reviewed is within the range of risk days;

Matching the type of disease to which the claim order to be reviewed belongs and the risky disease.

It should be noted that the terminal in the embodiment of the present application may be used to implement all the technical solutions in the foregoing method embodiments. It will be clearly understood by those skilled in the art that, for convenience and brevity of description, only the division of each functional unit and module described above is exemplified. In practical applications, the above functions may be assigned to different functional units according to needs. The module is completed by dividing the internal structure of the device into different functional units or modules to perform all or part of the functions described above.

In the above embodiments, the descriptions of the various embodiments are different, and the parts that are not detailed or described in the specific embodiments may be referred to the related descriptions of other embodiments.

FIG. 5 is a schematic diagram of a terminal according to an embodiment of the present application. As shown in FIG. 5, the terminal 5 of this embodiment includes a processor 50, a memory 51, and computer readable instructions 52 stored in the memory 51 and executable on the processor 50. The processor 50 executes the computer readable instructions 52 to implement the steps in the embodiment of the personalized review method of the claim order, such as steps S101 to S104 shown in FIG. 1 and steps S201 to S202 shown in FIG. Steps S301 to S303 shown in FIG. Alternatively, the processor 50 implements the functions of the modules/units in the embodiment of the personalized review device of the claim order when the computer readable instructions 52 are executed, such as the functions of the modules 41 to 46 shown in FIG.

It will be understood that one or more non-volatile readable storage media storing computer readable instructions may comprise: any entity or device capable of carrying the computer readable instruction code, a recording medium, a USB flash drive, a mobile hard drive, Disk, optical disk, computer memory, Read-Only Memory (ROM), Random Access Memory (RAM), electrical carrier signals, telecommunications signals, and software distribution media.

The above-mentioned embodiments are only used to explain the technical solutions of the present application, and are not limited thereto; although the present application has been described in detail with reference to the foregoing embodiments, those skilled in the art should understand that they can still implement the foregoing embodiments. The technical solutions described in the examples are modified or equivalently replaced with some of the technical features; and the modifications or substitutions do not deviate from the spirit and scope of the technical solutions of the embodiments of the present application, and should be included in Within the scope of protection of this application.

Claims (20)

1. A personalized review method for a claim order, characterized in that the personalized review method comprises:

   Obtaining an auditing rule configured by the organization administrator in the auditing rule configuration interface, and correlating the auditing rule with an organization code corresponding to the organization administrator;

   When receiving the automatic audit instruction, the approval process of the claim order is started, and the claim code of the claim and the institution code of the accepting institution are obtained;

   Performing an automated audit of the claim order to be audited according to the audit rule associated with the institution code, and obtaining a claim order and its detailed information that does not meet the audit rule;

   The claim order and its detailed information that do not meet the audit rules are distributed to the corresponding receiving institution for manual review.
2. The personalization review method of claim order according to claim 1, wherein before the obtaining an auditing rule configured by the organization administrator in the auditing rule configuration interface, the auditing method further includes:

   Obtaining the account information of the requester when receiving the configuration instruction of the audit rule;

   The account information is matched with an administrator account, and if the account information is an administrator account, the audit rule configuration interface is displayed.
3. The personalized review method for a claim order according to claim 1, wherein after the claim order and the detailed information that does not meet the audit rule are distributed to the corresponding accepting institution for manual review, the method further includes :

   Start the monitoring thread according to the preset time;

   Reading, by the monitoring thread, a preset SQL statement, querying the database according to the SQL statement, and obtaining the claim code of the settlement order and the institution code of the receiving institution that was closed the previous day;

   Sending the claim order to the corresponding receiving institution according to the agency code, so that the receiving institution performs risk analysis on the audit rule configured by the receiving institution;

   Wherein, the claim order includes a claim order through automatic review and a claim order through manual review.
4. The personalized review method for a claim order according to any one of claims 1 to 3, characterized in that the configured audit rule comprises one of the following or any combination thereof:

   The adjustment order of the configuration claim order is the first accident after the disease, the disease after the accident or the most favorable to the customer;

   The compensation amount is configured, and the compensation amount is a judgment criterion for determining a claim settlement to manual review based on the compensation amount;

   The number of risk days is configured, and the number of risk days is a judgment criterion for determining a claim settlement to manual review based on the effective date of the commitment;

   A risk disease is configured, which is a criterion for determining a claim-to-manual review based on the type of disease.
5. The personalized review method of the claim order according to claim 4, wherein the automated review of the claim order to be audited according to the audit rule associated with the agency code comprises:

   Traversing each claim order to be reviewed, comparing the amount of the claim to be reviewed and the claim amount;

   Verifying whether the number of days of effective coverage of the claims to be reviewed is within the range of risk days;

   Matching the type of disease to which the claim order to be reviewed belongs and the risky disease.
6. A personalized review device for a claim order, characterized in that the review device comprises:

   The association module is configured to obtain an audit rule configured by the organization administrator in the audit rule configuration interface, and associate the audit rule with an organization code corresponding to the organization administrator;

   The obtaining module is configured to start an auditing process of the claim order when receiving the automatic auditing instruction, and obtain the institution code of the claim order to be audited and the receiving institution;

   An auditing module, configured to automatically review the claim order to be audited according to the auditing rule associated with the institution code, and obtain a claim order and its detailed information that does not meet the auditing rule;

   The distribution module is configured to distribute the claim order and the detailed information that does not meet the audit rule to the corresponding receiving institution for manual review.
7. The device of claim 6 is characterized in that the review device further comprises:

   The verification module is configured to: when receiving the configuration instruction of the audit rule, obtain the account information of the requester; match the account information with the administrator account, and display the audit rule if the account information is an administrator account Configuration interface.
8. The device of claim 6 is characterized in that the review device further comprises:

   The monitoring module is configured to start the monitoring thread according to the preset time; read the preset SQL statement by the monitoring thread, query the database according to the SQL statement, and obtain the claim code of the settlement order and the receiving institution of the previous day; The mechanism code sends the claim order to a corresponding accepting institution, so that the accepting institution performs risk analysis on the audit rule configured by the receiving institution;

   Wherein, the claim order includes a claim order through automatic review and a claim order through manual review.
9. A personalization review apparatus for a claim order according to any one of claims 6 to 8, wherein the configured audit rule comprises one or any combination of the following:

   The adjustment order of the configuration claim order is the first accident after the disease, the disease after the accident or the most favorable to the customer;

   The compensation amount is configured, and the compensation amount is a judgment criterion for determining a claim settlement to manual review based on the compensation amount;

   The number of risk days is configured, and the number of risk days is a judgment criterion for determining a claim settlement to manual review based on the effective date of the commitment;

   A risk disease is configured, which is a criterion for determining a claim-to-manual review based on the type of disease.
10. The personalization review apparatus of the claim order according to claim 9, wherein the auditing module is specifically configured to:

    Traversing each claim order to be reviewed, comparing the amount of the claim to be reviewed and the claim amount;

    Verifying whether the number of days of effective coverage of the claims to be reviewed is within the range of risk days;

    Matching the type of disease to which the claim order to be reviewed belongs and the risky disease.
11. One or more non-transitory readable storage mediums storing computer readable instructions, wherein when the computer readable instructions are executed by one or more processors, cause the one or more processors to execute The following steps:

    Obtaining an auditing rule configured by the organization administrator in the auditing rule configuration interface, and correlating the auditing rule with an organization code corresponding to the organization administrator;

    When receiving the automatic audit instruction, the approval process of the claim order is started, and the claim code of the claim and the institution code of the accepting institution are obtained;

    Performing an automated audit of the claim order to be audited according to the audit rule associated with the institution code, and obtaining a claim order and its detailed information that does not meet the audit rule;

    The claim order and its detailed information that do not meet the audit rules are distributed to the corresponding receiving institution for manual review.
12. A non-volatile readable storage medium as recited in claim 11, wherein said computer readable instructions are executed by one or more processors prior to obtaining an auditing rule configured by an organization administrator in an auditing rules configuration interface When executed, the one or more processors are further configured to perform the following steps:

    Obtaining the account information of the requester when receiving the configuration instruction of the audit rule;

    The account information is matched with an administrator account, and if the account information is an administrator account, the audit rule configuration interface is displayed.
13. The non-volatile readable storage medium according to claim 11, wherein after the claim order and the detailed information thereof that do not comply with the audit rule are distributed to a corresponding receiving institution for manual review, the computer can When the read instruction is executed by one or more processors, the one or more processors further perform the following steps:

    Start the monitoring thread according to the preset time;

    Reading, by the monitoring thread, a preset SQL statement, querying the database according to the SQL statement, and acquiring the claim order of the settlement day and the institution code of the receiving institution;

    Sending the claim order to the corresponding receiving institution according to the agency code, so that the receiving institution performs risk analysis on the audit rule configured by the receiving institution;

    Wherein, the claim order includes a claim order through automatic review and a claim order through manual review.
14. The non-volatile readable storage medium according to any one of claims 11 to 13, wherein the configured audit rule comprises one or any combination of the following:

    The adjustment order of the configuration claim order is the first accident after the disease, the disease after the accident or the most favorable to the customer;

    The compensation amount is configured, and the compensation amount is a judgment criterion for determining a claim settlement to manual review based on the compensation amount;

    The number of risk days is configured, and the number of risk days is a judgment criterion for determining a claim settlement to manual review based on the effective date of the commitment;

    A risk disease is configured, which is a criterion for determining a claim-to-manual review based on the type of disease.
15. The non-volatile readable storage medium of claim 14, wherein the automated review of the claim order to be reviewed according to the audit rule associated with the agency code comprises:

    Traversing each claim order to be reviewed, comparing the amount of the claim to be reviewed and the claim amount;

    Verifying whether the number of days of effective coverage of the claims to be reviewed is within the range of risk days;

    Matching the type of disease to which the claim order to be reviewed belongs and the risky disease.
16. A terminal comprising a memory, a processor, and computer readable instructions stored on the memory and operable on the processor, wherein the processor, when executing the computer readable instructions, implements the following steps:

    Obtaining an auditing rule configured by the organization administrator in the auditing rule configuration interface, and correlating the auditing rule with an organization code corresponding to the organization administrator;

    When receiving the automatic audit instruction, the approval process of the claim order is started, and the claim code of the claim and the institution code of the accepting institution are obtained;

    Performing an automated audit of the claim order to be audited according to the audit rule associated with the institution code, and obtaining a claim order and its detailed information that does not meet the audit rule;

    The claim order and its detailed information that do not meet the audit rules are distributed to the corresponding receiving institution for manual review.
17. The terminal according to claim 16, wherein the processor further implements the following steps when the processor executes the computer readable instructions before the auditing authority configures the auditing rules configured by the rules configuration interface:

    Obtaining the account information of the requester when receiving the configuration instruction of the audit rule;

    The account information is matched with an administrator account, and if the account information is an administrator account, the audit rule configuration interface is displayed.
18. The terminal according to claim 16, wherein said processor executes said computer readable instruction after distributing the claim order and the detail information that do not conform to said audit rule to a corresponding receiving institution for manual review The following steps are also implemented:

    Start the monitoring thread according to the preset time;

    Reading, by the monitoring thread, a preset SQL statement, querying the database according to the SQL statement, and obtaining the claim code of the settlement order and the institution code of the receiving institution that was closed the previous day;

    Sending the claim order to the corresponding receiving institution according to the agency code, so that the receiving institution performs risk analysis on the audit rule configured by the receiving institution;

    Wherein, the claim order includes a claim order through automatic review and a claim order through manual review.
19. The terminal according to any one of claims 16 to 18, wherein the configured audit rule comprises one of the following or any combination thereof:

    The adjustment order of the configuration claim order is the first accident after the disease, the disease after the accident or the most favorable to the customer;

    The compensation amount is configured, and the compensation amount is a judgment criterion for determining a claim settlement to manual review based on the compensation amount;

    The number of risk days is configured, and the number of risk days is a judgment criterion for determining a claim settlement to manual review based on the effective date of the commitment;

    A risk disease is configured, which is a criterion for determining a claim-to-manual review based on the type of disease.
20. The terminal according to claim 19, wherein the automated review of the claim order to be audited according to the audit rule associated with the organization code comprises:

    Traversing each claim order to be reviewed, comparing the amount of the claim to be reviewed and the claim amount;

    Verifying whether the number of days of effective coverage of the claims to be reviewed is within the range of risk days;

    Matching the type of disease to which the claim order to be reviewed belongs and the risky disease.

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