CN106530090A - Medical claim settlement system and method - Google Patents
Medical claim settlement system and method Download PDFInfo
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Abstract
A medical claim settlement method comprises that medical claim settlement data of a bill is received; an allowance is calculated according to the medical claim settlement data; waiting-period verification is implemented on the medical claim settlement data, and a waiting-period verification result is generated; pre-authorization matching is carried out on the medical claim settlement data; and claim settlement calculation is carried out on the medical claim settlement data, and a claim settlement result is generated and output. The invention also provides a medical claim settlement system. The system and method can be used to realize automatic calculation for medical insurances.
Description
Technical field
The present invention relates to data regulation technique field, particularly a kind of medical treatment Claims Resolution system and method.
Background technology
Insurance company has that medical expense Claims Resolution process is slower mostly at present, one of major reason
It is that confirmation of responsibility link needs artificial participation, it is impossible to accomplish full-automatic adjustment, and poor user experience.
The content of the invention
In view of the foregoing, it is necessary to a kind of medical treatment Claims Resolution system and method is provided, can be realized to medical treatment guarantor
The automatic adjustment of danger.
A kind of medical Claims Resolution method, the method include：
Receive the medical treatment Claims Resolution data of bill；
Subsidy is calculated according to medical treatment Claims Resolution data；
Waiting period verification is performed to medical treatment Claims Resolution data, waiting period check results are generated；
Pre-authorization matching is performed to medical treatment Claims Resolution data；And
Claims Resolution calculating is carried out to the medical treatment Claims Resolution data, Claims Resolution result is generated, and is exported the Claims Resolution result.
Preferably, the waiting period verification includes personal waiting period verification and the verification of Protocol latency phase.
Preferably, it is described that medical treatment Claims Resolution data execution pre-authorization matching is included：Pre-authorization project is obtained, is held
Row Claims Resolution head with settle a claim line respectively with the pre-authorization head of pre-authorization project and matching for pre-authorization line.
Preferably, before subsidy is calculated, the method also includes：The medical treatment Claims Resolution data are carried out effectively
Property inspection, Repeatability checking and responsibility matching.
A kind of system suitable for said method, which includes multiple modules, for real under the execution of processor
Existing following step：
Receive the medical treatment Claims Resolution data of bill；
Subsidy is calculated according to medical treatment Claims Resolution data；
Waiting period verification is performed to medical treatment Claims Resolution data, waiting period check results are generated；
Pre-authorization matching is performed to medical treatment Claims Resolution data；And
Claims Resolution calculating is carried out to the medical treatment Claims Resolution data, Claims Resolution result is generated, and is exported the Claims Resolution result.
Preferably, the waiting period verification includes personal waiting period verification and the verification of Protocol latency phase.
Preferably, before subsidy is calculated, the processor is also executed the following steps：To the medical treatment Claims Resolution
Data carry out the matching of validity check, Repeatability checking and responsibility.
Preferably, it is described that medical treatment Claims Resolution data execution pre-authorization matching is included：Pre-authorization project is obtained, is held
Row Claims Resolution head with settle a claim line respectively with the pre-authorization head of pre-authorization project and matching for pre-authorization line.
The automatic adjustment to medical care insurance can be realized using medical treatment Claims Resolution system and method for the present invention.
Description of the drawings
Fig. 1 is the hardware environment figure of medical treatment Claims Resolution system preferred embodiment of the invention.
Fig. 2 is the functional block diagram of medical treatment Claims Resolution system preferred embodiment of the invention.
Fig. 3 is the method implementing procedure figure of medical treatment Claims Resolution method preferred embodiment of the invention.
Fig. 4 to Fig. 6 is the detailed implementing procedure figure of step S12 in method shown in Fig. 3.
Fig. 7 is the detailed implementing procedure figure of step S13 in method shown in Fig. 3.
Fig. 8 A to Fig. 8 C are the detailed implementing procedure figures of step S14 in method shown in Fig. 3.
Specific embodiment
Refering to the hardware environment figure for shown in Fig. 1, being medical treatment Claims Resolution system preferred embodiment of the invention.This enforcement
In example, the medical Claims Resolution system basic service flow process is：The medical bill information of insurant 3 is by doctor
The settlement system for treating mechanism 2 generates medical treatment Claims Resolution data.The medical treatment Claims Resolution data are transmitted periodically or in real time
To Medical Insurance Organizations 1.Medical Insurance Organizations 1 can by it is described medical treatment settle a claim data storage in data base 3,
And the medical treatment Claims Resolution data are received using medical Claims Resolution system 10, the medical treatment to obtaining is settled a claim at data
Reason, such as calculates subsidy data, performs waiting period verification, pre-authorization matching and carry out Claims Resolution calculating, generate
Claims Resolution result, and export the Claims Resolution result.
The Medical Insurance Organizations 1 are led to the medical institutions 2 by network, such as LAN or the Internet
News connection.
The Medical Insurance Organizations 1 can be various places social security office or banking and insurance business mechanism etc., the therapeutic machine
Structure 2 can be the hospital of each rank of various places.
The medical Claims Resolution system 10 of the Medical Insurance Organizations 1 can be a server system.The server
System as a hardware system, with higher computing capability.The main hardware of the server system is constituted
Comprising following several major parts：Central processing unit, internal memory, chipset, I/O buses, I/O equipment, electricity
Source, cabinet and related software.
In other embodiments of the invention, the medical Claims Resolution system 10 of the Medical Insurance Organizations 1 can also
It is a software system being made up of program code, which can be installed and run on and arbitrarily have higher meter
In the server of calculation ability or any personal electric product, in the process of the server or electronic product
Under the execution of device, such as central processing unit (CPU, Central Processing Unit), realize that certain is default
The medical Claims Resolution data are such as processed by function, verify as calculated subsidy data, execution waiting period,
Pre-authorization matches and carries out Claims Resolution calculating, generates Claims Resolution result, and exports the Claims Resolution result.
Refering to the functional block diagram for described in Fig. 2, being medical treatment Claims Resolution system preferred embodiment of the invention.The present invention
The medical Claims Resolution system 10 is bottom-up to be divided into interface layer, operation layer and boundary layer.
The interface layer externally provides various interface mode, and which includes interface module 100.The interface module
100 include data-interface, service interface and/or other access API etc..The data-interface can be USB
Interface, serial ports, infrared interface and blue tooth interface etc., are the interfaces for carrying out data transmission, e.g., from medical treatment
Mechanism 2 or data base 3 receive medical treatment Claims Resolution data.
The operation layer is the core of whole medical treatment Claims Resolution system 10, it include subsidy computing module 101, etc.
Treat phase correction verification module 102, pre-authorization matching module 103 and Claims Resolution computing module 104.The operation layer
Each module is processed for the medical treatment Claims Resolution data received from interface module 100, such as calculate subsidy data,
Perform waiting period verification, pre-authorization matching and carry out Claims Resolution calculating, generate Claims Resolution result etc..
The boundary layer is responsible for representing and man-machine interaction for interface, and which includes display module 105 and rule system
Cover half block 106.The display module 105 is used for showing the centre or final to the medical treatment Claims Resolution data
Result, such as Claims Resolution result for being generated etc..The regular designated module 106 is used for specifying to the doctor
Treat the process rule of Claims Resolution data.
Hereinafter, with reference to Fig. 3, describe the function of above-mentioned each module in detail.
Refering to the method implementing procedure figure for shown in Fig. 3, being medical treatment Claims Resolution method preferred embodiment of the invention.This
Described in embodiment, medical Claims Resolution method is not limited to step shown in flow chart, in addition step shown in flow chart
In, some steps can be omitted, the order between step can change.
Step S10, the interface module 100 receive the medical treatment Claims Resolution data of bill.Present pre-ferred embodiments
In, the diagnosis information of insurant 3 generates medical treatment Claims Resolution data, institute by the settlement system of medical institutions 2
State medical treatment Claims Resolution data periodically or be real-time transmitted to Medical Insurance Organizations 1, and by 100 institute of the interface module
Receive.
Step S11, the subsidy computing module 101 calculate subsidy according to medical treatment Claims Resolution data.In the present embodiment,
The subsidy responsibility is included：
GHE：In hospital without Claims Resolution day volume subsidy 31150001；
H012：Hospital day volume allowance insurance gold 31000001；And
H012：Discharge is recuperated a day volume allowance insurance gold 31000014.
Adjustment formula：Day Sum Limited x length of stay (Claims Resolution line number amount)=subsidy responsibility compensates the amount of money.
Step S12,102 pairs of medical treatment Claims Resolution data of the waiting period correction verification module perform waiting period verification, generate
Waiting period check results.In the present embodiment, the waiting period verification includes personal waiting period verification and agreement
Waiting period verifies.In the present embodiment, the detail flowchart that medical treatment Claims Resolution data are performed with waiting period verification
Refer to the description of following Fig. 4-6.
Step S13,103 pairs of medical treatment Claims Resolution data of the pre-authorization matching module perform pre-authorization matching, obtain
Pre-authorization project, perform Claims Resolution head with Claims Resolution line respectively with the pre-authorization head and pre-authorization line of pre-authorization project
Matching.In the present embodiment, the detail flowchart of the pre-authorization matching to medical treatment Claims Resolution data is referred to down
The description of the Fig. 7 for stating.
Step S14, the medical treatment Claims Resolution data of the Claims Resolution computing module 104 pairs carry out Claims Resolution calculating, generate
Claims Resolution result, exports Claims Resolution result by the display module 105, and result is recorded in data base 3
In.
In the other embodiment of the present invention, before step S11, can also include, to the medical treatment Claims Resolution
Data carry out the matching of validity check, Repeatability checking and responsibility.
Fig. 4 to Fig. 6 is step S12 in medical Claims Resolution method shown in Fig. 3, i.e., medical treatment Claims Resolution data are performed etc.
Treat the detailed implementing procedure figure of phase verification.Described in the present embodiment, medical Claims Resolution method is not limited to institute in flow chart
Show step, in addition shown in flow chart in step, some steps can be omitted, the order between step can be with
Change.
Refering to shown in Fig. 4, step S20, the waiting period correction verification module 102 judge whether insurant removes
External information.Except described, information includes that general waiting period, personal core protect decision, personal waiting period etc..It is described
Waiting period refers to the wait date that the declaration form of insurant comes into force, and such as waiting period is 30 days, then declaration form comes into force
30 Tian Nei insurance companies do not undertake related insurance responsibility, just undertake insurance responsibility, i.e., 30 day afterwards after 30 days
Could settle a claim.The general waiting period is detailed for responsibility, that is, the people of the insurance kind of having insured typically can
Some waiting periods, personal waiting period are for personal.Core guarantor's decision is referred to will carry out core guarantor, core after insuring
Guarantor can just accept insurance by rear, the core that can pass through protect decision be generally divided into standard type pass through, plus expense, except, restriction
Protection amount etc., core are protected if being determined as declinaturing and cannot be accepted insurance.Personal core is protected and determines that the core for being aiming at individual is protected
Determine.
If insurant does not remove external information, terminate flow process.Otherwise, if insurant has except external information,
Then step S21, the waiting period correction verification module 102 circulate every bill line.Step S22, the waiting period
Correction verification module 102 judge it is described except information type whether be general waiting period, such as except information type ID
For 4834.If except described, information type is general waiting period, execution step S23.Otherwise, if except
Information type is not general waiting period, then perform following steps S25.In step S23, the waiting period
Whether correction verification module 102 judges service date service_date on line except in time interval.If on line
The service date except in time interval, then execution step S24.Otherwise, if the service date on line does not exist
Except in time interval, then perform following steps S25.In step s 24, the waiting period correction verification module
Corresponding result ID of 102 outputs, such as GENERAL_WAITING_PERIOD (70043).In step S25
In, the waiting period correction verification module 102 determine whether it is described except information type be whether that personal core is protected and determined
It is fixed, if the ID of information type except described is 4835.If information type is that personal core protects decision except described,
Then execution step S26.Otherwise, if information type is not that personal core protects decision, execution step except described
S29.In step S26, the waiting period correction verification module 102 judges the service date service_date on line
Whether except in time interval.If the service date service_date on line is except in time interval,
Execution step S27.Otherwise, if the service date service_date on line is not except in time interval,
Execution step S29.In step s 27, whether the waiting period correction verification module 102 judges current bill line
Without manual amendment.If current bill line is without manual amendment, execution step S28.Otherwise, if
Current bill line through manual amendment, then execution step S29.In step S28, corresponding result is exported
ID, such as CUSTOM_WAITING_PERIOD (20003).In step S29, the waiting period verification
Except module 102 judges, whether information type is personal waiting period, and as except, the ID of information type is 4836.
If except information type be personal waiting period, execution step S30.Otherwise, if except type be not individual etc.
Treat the phase, then terminate flow process.In step S30, the waiting period correction verification module 102 judges the service date on line
Whether service_date is except in time interval.If the service date on line is except in time interval,
Execution step S31.If the service date on line, not except in time interval, terminates flow process.In step
In S31, the waiting period correction verification module 102 judge except benefit benefit and product product whether and
It is consistent on line.If consistent, execution step S32.If inconsistent, terminate flow process.In step s 32,
The waiting period correction verification module 102 exports corresponding result ID, such as
BENEFIT_WAITING_PERIOD(20008)。
Refering to shown in Fig. 5, step S40, the waiting period correction verification module 102 circulate every bill line.Step
S41, the waiting period correction verification module 102 judge whether there is product product on line.If answer is yes, hold
Row step S42.If answer is no, terminate flow process.In step S42, the waiting period correction verification module
102 judge whether the product on line has the first default mark, such as HAS_CONTRACT_DEFINITION
FLAG.If having the described first default mark, execution step S43.If there is no the described first default mark,
Step S44 is performed then.In step S43, the waiting period correction verification module 102 exports corresponding result
ID, such as HAS_CONTRACT_DEFINITION (20005).In step S44, the waiting period school
Test whether the product product that module 102 judged on line has the second default mark, such as
HAS_SPECIAL_AGREEMENT FLAG.If having the second default mark, execution step S45.If
There is no the second default mark, then terminate flow process.In step S45, the waiting period correction verification module 102 is defeated
Go out corresponding result ID, such as HAS_SPECIAL_AGREEMENT (20006).
Refering to shown in Fig. 6, step S50, the waiting period correction verification module 102 circulate every bill line.Step
S51, the waiting period correction verification module 102 judge whether have a responsibility for detail on line.If having a responsibility for detail, hold
Row step S52.Otherwise, if no responsibility is detailed, terminate flow process.In step S52, the waiting period
Correction verification module 102 judges whether responsibility detail defines waiting period.If defining waiting period, execution step S53.
Otherwise, if not defining waiting period, terminate flow process.In step S53, the waiting period correction verification module
The 102 tactful startDateStrategy for judging Start Date.If the strategy of Start Date is condition starting
CONDITION_START, then execution step S54.If the strategy of Start Date is strategy starting
POLICY_START, then execution step S55.In step S54, the waiting period correction verification module 102
The date that setting Start Date starts for condition, such as Start_date=ConditionStartDate.In step S55
In, the waiting period correction verification module 102 arranges the effective date for Start Date being equal to product, such as Start_date
Equal to the effective date of product Product.Step S56, the waiting period correction verification module 102 arrange closing day
Phase, such as setting Close Date are Start Date to add a preset value, such as End_date=start_date+
Underwriting.getDays()+underwriting.getMonths().Step S57, the waiting period calibration mode
Whether block 102 judges the online service date between Start Date and Close Date.If the online service date exists
Between Start Date and Close Date, in execution step S58.If the online service date is not in Start Date and knot
Between the beam date, then terminate flow process.In step S58, the output of waiting period correction verification module 102 correspondence
Result ID, such as BENEFIT_DEFINED_WAITING_PERIOD (20209).
Refering to shown in Fig. 7, being step S13 in medical Claims Resolution method shown in Fig. 3, i.e., medical treatment Claims Resolution data are held
The detailed implementing procedure figure of row pre-authorization matching.Described in the present embodiment, medical Claims Resolution method is not limited to flow chart
Shown in step, in addition shown in flow chart in step, some steps can be omitted, the order between step
Can change.
Step S60, the pre-authorization matching module 103 obtain the pre-authorization project that can be matched from protocol definition.
In the present embodiment, obtaining the pre-authorization project that can be matched from protocol definition includes：
Whether step S61, the pre-authorization matching module 103 define pre-authorization project in judging agreement.If
Pre-authorization project is not defined in agreement, then terminate flow process.Otherwise, if pre-authorization project defined in agreement,
Then execution step S62.
In step S62, the pre-authorization matching module 103 judges whether Claims Resolution head has pre-authorization.If not yet
There is pre-authorization, then execution step S63, export corresponding result ID, such as outcome_ID：50007.
If Claims Resolution head has pre-authorization, execution step S64, the pre-authorization matching module 103 judge pre-authorization
Mdc and Claims Resolution ICD whether match.If mismatching, above-mentioned step S63 is performed.The mdc is
Refer to disease big class, the ICD is a kind of disease code.The matching refers to that for example osteodynia is matched with orthopaedics.
If the mdc of pre-authorization and Claims Resolution ICD matchings, step S65, the pre-authorization matching module 103
Judge statement date whether within the pre-authorization effect duration.If before the deadline, not performing above-mentioned step S63.
If statement date, within the pre-authorization effect duration, step S66, the pre-authorization matching module 103 enter one
Step judges whether the hospital of Claims Resolution bill is consistent with pre-authorization hospital.If inconsistent, above-mentioned step is performed
S63。
If the hospital of Claims Resolution bill is consistent with pre-authorization hospital, step S67, the pre-authorization matching module
103 matching Claims Resolution lines and pre-authorization project.
In the present embodiment, the matching Claims Resolution line is included with pre-authorization project：
Step S68, the pre-authorization matching module 103 judge whether Claims Resolution line is matched with pre-authorization.If not
Match somebody with somebody, then perform above-mentioned step S63.
If Claims Resolution line is matched with pre-authorization, step S69, the pre-authorization matching module 103 judges Claims Resolution line
Whether default mark, such as Non-notification flag are had.If there is default mark, execution step S70, institute
State pre-authorization matching module 103 and sentence addition punishment ratio.Otherwise, if there is no the default mark, perform
Step S71, the pre-authorization matching module 103 judge whether pre-authorization conclusion is refusal.If refusal, then
Step S72, the pre-authorization matching module 103 export corresponding result ID, such as outcome_ID：50009.
If pre-authorization conclusion is not refusal, step S73, the pre-authorization matching module 103 are determined whether
Whether pre-authorization conclusion is without decision.If without decision, then step S74, exports corresponding result ID, such as
outcome_ID：20007.Otherwise, if pre-authorization conclusion is not without decision, terminate flow process.
Refering to shown in Fig. 8 A to Fig. 8 C, being step S14 in medical Claims Resolution method shown in Fig. 3, i.e., to described
Medical treatment Claims Resolution data carry out the detailed implementing procedure figure of Claims Resolution calculating.Medical Claims Resolution method described in the present embodiment is simultaneously
Step shown in flow chart is not limited to, in addition shown in flow chart in step, some steps can be omitted, be walked
Order between rapid can change.
Step S80, the Claims Resolution computing module 104 determine whether virtual subsidy line.If no virtual subsidy
Line, then execution step S81.If there is virtual subsidy line, following steps S85 are performed.
In step S81, the Claims Resolution computing module 104 judges whether bill has discount.If there is discount, hold
Row step S82 and S83.If no discount, execution step S84.
In step S82, the Claims Resolution computing module 104 shares discount amount to Claims Resolution line, and in step
S83, the Claims Resolution computing module 104 export corresponding result ID, such as outcome_ID：50001.
In step S84, the Claims Resolution computing module 104 judges whether output result ID of Claims Resolution line refuses to pay
Type does not match responsibility.If answer is yes, terminate flow process.If answer is no, execution step S85.
In step S85, the Claims Resolution computing module 104 calculates deductible excess.Step S86, the Claims Resolution are calculated
Module 104 obtains the deductible excess of responsibility.Step 87, the Claims Resolution computing module 104 determine whether abatement
Volume.If no deductible excess, execution step S88.If having deductible excess, execution step S89.
In step S88, the Claims Resolution computing module 104 calculates compensation ratio.In step S89, the Claims Resolution
Computing module 104 judges whether to reach the deductible excess upper limit.If reaching the deductible excess upper limit, above-mentioned step is performed
Rapid S88.If being not reaching to the deductible excess upper limit, execution step S90, the Claims Resolution computing module 104 judge
Whether limit is paid for oneself.If paying limit for oneself, execution step S91, the Claims Resolution computing module 104 are obtained
Pay limit for oneself, and in step S92, further determine whether to reach and pay the limit upper limit for oneself.If reach paying for oneself
The limit upper limit, then step S94, exports corresponding result ID, such as outcome_ID：50004.
If not paying limit for oneself or paying limit for oneself but be not reaching to pay the limit upper limit, step S93, institute for oneself
State Claims Resolution computing module 104 and calculate deductible excess.Step 95, the Claims Resolution computing module 104 calculate reasonable gold
Volume.Step S96, the Claims Resolution computing module 104 export corresponding result ID, such as outcome_ID：50002,
And then, perform above-mentioned step S88.
After step S88, execution step S97, the Claims Resolution computing module 104 obtain compensation ratio.Step
S98, the Claims Resolution computing module 104 judge whether that limit is paid in definition for oneself.If answer is yes, to execution step
S99.If answer is no, execution step S100.
In step S99, the Claims Resolution computing module 104 judges to pay whether limit has reached the upper limit for oneself.If no
The upper limit is reached, then execution step S100.If having reached the upper limit, execution step S104.
In step S100, the Claims Resolution computing module 104 calculates compensation ratio.Step S101, the Claims Resolution
Computing module 104 calculates fair amount.Step S102, the Claims Resolution computing module 104 judge compensation ratio
Whether it is 100%.If not 100%, then execution step S103, the Claims Resolution computing module 104 export right
Result ID answered, such as outcome_ID：50003, and execution step S104.If the ratio of compensation is 100%,
Then direct execution step S104.
In step S104, the Claims Resolution computing module 104 calculates particular hospital and compensates ratio.Step S105,
The Claims Resolution computing module 104 obtains bill hospital category.Step S106, the Claims Resolution computing module 104
Judge whether it is particular hospital.If particular hospital, then execution step S107.If not particular hospital, then
Execution step S109.
In step S107, the Claims Resolution computing module 104 obtains particular hospital and compensates ratio.Step S108,
The Claims Resolution computing module 104 exports corresponding result ID, such as outcome_ID：50005, and perform step
Rapid S109.
In step S109, the Claims Resolution computing module 104 calculates time limit.Step S110, the Claims Resolution meter
Calculate module 104 and obtain the limit of all triggering responsibilities, type.Step S111, the Claims Resolution computing module 104
Determine whether the manual amendment of MI/SMI.If answer is yes, execution step S112.As answer be it is no,
Then execution step S115.The MI/SMI amount of money is arranged and is limited by step S112, the Claims Resolution computing module 104
Volume.Step S113, the Claims Resolution computing module 104 judge whether it is SMI, in the present embodiment, described to sentence
It is disconnected be whether SMI be matching according to reason-code.If answer is yes, execution step S114.If answer
It is no, then execution step S115.Wherein, the SMI full name super manual instruction, MI full name
It is Manual instruction, both to be had any different in authority and can only change number of times and natural law for MI, and SMI
Except it is super it is insured amount in addition to what can change.
Step S114, the Claims Resolution computing module 104 arrange limit be to surpass but do not allow more than it is insured amount and
Billing amount.Step S116, the Claims Resolution computing module 104 judge whether limit exceedes insured amount or bill
The amount of money.If answer is yes, execution step S118, the Claims Resolution computing module 104 export corresponding result
ID, such as Outcome_ID：50012/50013/50017/50018.If judge limit whether exceed it is insured amount or
The answer of billing amount is no, then step S117, and the Claims Resolution computing module 104 calculates time limit, and holds
Row step S119.
In step S115, the Claims Resolution computing module 104 checks whether number of times, natural law, the amount of money reach the full quota
The upper limit.Step S120, the Claims Resolution computing module 104 judge whether number of times, natural law, the amount of money reach
Limit.If having reached the upper limit, then step S122, the Claims Resolution computing module 104 calculates the adjustment amount of money=secondary limit
The upper limit, and in step S123, export corresponding result ID, such as Outcome_ID：50006, and perform step
Rapid S119.If judging to be not reaching to the upper limit in step S120, execution step S121, the Claims Resolution are calculated
Module 104 calculates time limit, and execution step S119.
In step S119, the Claims Resolution computing module 104 calculates pre-authorization punishment ratio.Step S124, institute
State Claims Resolution computing module 104 and obtain pre-authorization conclusion.Step S125, the Claims Resolution computing module 104 judge
Whether there is a default label, such as Non notification flag or have default ID, such as Pre-auth no found
outcome Id.If answer is yes, step S126, the Claims Resolution computing module 104 obtain pre-authorization punishment
Ratio, and step S127, the Claims Resolution computing module 104 calculate fair amount.If the answer of step S125
It is no, then execution step S128, the Claims Resolution computing module 104 calculates compensation principle.Step S129, institute
State Claims Resolution computing module 104 and obtain the adjustment amount of money.Step S130, the Claims Resolution computing module 104 judge be
No billing amount-discount amount-third party pays in advance<The adjustment amount of money.If answer is no, perform following
The step of 133.If answer is yes, execution step S131, the Claims Resolution computing module 104 calculate compensation
Principle.The compensation principle amount of money is shared Claims Resolution line by step S132, the Claims Resolution computing module 104, again
Accumulative deductible excess, secondary limit etc..Step S133, the Claims Resolution computing module 104 export corresponding result ID,
Such as Outcome_ID：50011.
It should be noted last that, above example only to illustrate technical scheme and unrestricted,
Although being described in detail to the present invention with reference to preferred embodiment, one of ordinary skill in the art should manage
Solution, can modify to technical scheme or equivalent, without deviating from technical solution of the present invention
Spirit and scope.
Claims (8)
1. a kind of medical Claims Resolution method, it is characterised in that the method includes：
Receive the medical treatment Claims Resolution data of bill；
Subsidy is calculated according to medical treatment Claims Resolution data；
Waiting period verification is performed to medical treatment Claims Resolution data, waiting period check results are generated；
Pre-authorization matching is performed to medical treatment Claims Resolution data；And
Claims Resolution calculating is carried out to the medical treatment Claims Resolution data, Claims Resolution result is generated, and is exported the Claims Resolution result.
2. medical treatment Claims Resolution method as claimed in claim 1, it is characterised in that the waiting period verification includes individual
Waiting period verifies and the verification of Protocol latency phase.
3. medical treatment Claims Resolution method as claimed in claim 1, it is characterised in that described that medical treatment Claims Resolution data are performed
Pre-authorization matching includes：Obtain pre-authorization project, perform Claims Resolution head with Claims Resolution line respectively with pre-authorization project
The matching of pre-authorization head and pre-authorization line.
4. medical treatment Claims Resolution method as claimed in claim 1, it is characterised in that before subsidy is calculated, the party
Method also includes：The matching of validity check, Repeatability checking and responsibility is carried out to the medical treatment Claims Resolution data.
5. a kind of medical Claims Resolution system suitable for Claims 1-4 any one methods described, it is characterised in that
The medical Claims Resolution system includes multiple modules, for realizing following step under the execution of processor：
Receive the medical treatment Claims Resolution data of bill；
Subsidy is calculated according to medical treatment Claims Resolution data；
Waiting period verification is performed to medical treatment Claims Resolution data, waiting period check results are generated；
Pre-authorization matching is performed to medical treatment Claims Resolution data；And
Claims Resolution calculating is carried out to the medical treatment Claims Resolution data, Claims Resolution result is generated, and is exported the Claims Resolution result.
6. medical treatment Claims Resolution system as claimed in claim 5, it is characterised in that the waiting period verification includes individual
Waiting period verifies and the verification of Protocol latency phase.
7. medical treatment Claims Resolution system as claimed in claim 5, it is characterised in that before subsidy is calculated, the place
Reason device is also executed the following steps：To it is described medical treatment Claims Resolution data carry out validity check, Repeatability checking and
Responsibility is matched.
8. medical treatment Claims Resolution system as claimed in claim 5, it is characterised in that described that medical treatment Claims Resolution data are performed
Pre-authorization matching includes：Obtain pre-authorization project, perform Claims Resolution head with Claims Resolution line respectively with pre-authorization project
The matching of pre-authorization head and pre-authorization line.
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| CN201510586443.8A CN106530090A (en) | 2015-09-15 | 2015-09-15 | Medical claim settlement system and method |
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| CN201510586443.8A CN106530090A (en) | 2015-09-15 | 2015-09-15 | Medical claim settlement system and method |
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| CN106530090A true CN106530090A (en) | 2017-03-22 |
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| CN201510586443.8A Pending CN106530090A (en) | 2015-09-15 | 2015-09-15 | Medical claim settlement system and method |
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| CN107180389A (en) * | 2017-05-10 | 2017-09-19 | 平安科技（深圳）有限公司 | People's wound Claims Resolution setting loss fee calculating method, device, server and medium |
| CN107679995A (en) * | 2017-08-31 | 2018-02-09 | 平安科技（深圳）有限公司 | Electronic installation, insurance case Claims Review method and computer-readable recording medium |
| CN107705211A (en) * | 2017-11-10 | 2018-02-16 | 平安科技（深圳）有限公司 | A kind of adjustment method and apparatus of settlement of insurance claim case |
| CN108053329A (en) * | 2018-01-19 | 2018-05-18 | 泰康保险集团股份有限公司 | For the information processing method of settlement of insurance claim, device, medium and electronic equipment |
| CN108257020A (en) * | 2017-04-07 | 2018-07-06 | 平安科技（深圳）有限公司 | A kind of computational methods and device of gold of settling a claim |
| CN108399574A (en) * | 2018-02-28 | 2018-08-14 | 泰康保险集团股份有限公司 | Claims Resolution data capture method, docking Claims Resolution subsystem, medium and electronic equipment |
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| CN108520465A (en) * | 2017-09-13 | 2018-09-11 | 平安科技（深圳）有限公司 | Medical insurance Claims Resolution method, apparatus, computer equipment and storage medium |
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| CN108399574A (en) * | 2018-02-28 | 2018-08-14 | 泰康保险集团股份有限公司 | Claims Resolution data capture method, docking Claims Resolution subsystem, medium and electronic equipment |
| CN108399574B (en) * | 2018-02-28 | 2021-09-28 | 泰康保险集团股份有限公司 | Claim data acquisition method, butt-joint claim subsystem, medium and electronic equipment |
| CN109461085A (en) * | 2018-09-26 | 2019-03-12 | 平安健康保险股份有限公司 | Claims Resolution data code matching process, device, computer equipment and storage medium |
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| CN109461085B (en) * | 2018-09-26 | 2024-04-26 | 平安健康保险股份有限公司 | Method, device, computer equipment and storage medium for matching claim data codes |
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