CN107895286B - Claim amount determining method and device, storage medium and electronic equipment - Google Patents
Claim amount determining method and device, storage medium and electronic equipment Download PDFInfo
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- CN107895286B CN107895286B CN201711116809.0A CN201711116809A CN107895286B CN 107895286 B CN107895286 B CN 107895286B CN 201711116809 A CN201711116809 A CN 201711116809A CN 107895286 B CN107895286 B CN 107895286B
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Abstract
The invention discloses a method and a device for determining a claim settlement amount, a storage medium and electronic equipment, and relates to the technical field of data processing. The method for determining the claim amount comprises the following steps: abstracting an claim settlement model based on policy data; generating a rule engine according to the claim settlement model and by combining a syntax analyzer; acquiring claim application data; and processing the claim application data based on the claim rules provided by the rules engine to determine a claim amount. The method and the system can construct a rule engine of exclusive insurance claim settlement, can realize the decoupling of claim settlement business rules and other system programs, and improve the processing efficiency of claim settlement business.
Description
Technical Field
The present disclosure relates to the field of data processing technologies, and in particular, to a claim amount determining method, a claim amount determining apparatus, a storage medium, and an electronic device.
Background
In the insurance industry, the process of claim settlement of various dangerous varieties is often involved, and the process of claim settlement depends on a large number of auditing rules and calculation rules for implementation. Currently, the claim settlement process is generally implemented in the following two ways. In the first mode, the auditing rule and the calculating rule can be directly realized in a program coding mode, namely, the business rule and the code of the insurance system are integrated; in a second manner, the configuration of the audit rules and the calculation rules can be implemented by introducing a general rule engine, fig. 1 shows an interactive processing procedure of this manner, specifically, the rule engine 12 can be deployed on a server separately, the rule engine 12 provides a function of rule configuration, and business personnel or developers configure rules through corresponding interfaces; the rules engine 12 may maintain a rules database 11; the claim settlement system 13 calls the rule engine 12 through interfaces such as WebService and HTTP to trigger the execution of the rule, thereby implementing the execution of the checksum calculation rule of the claim settlement audit rule.
However, in the first method, since the business rules and the codes of the insurance system are integrated, the coupling degree between them is high, and the adjustment of the business rules and the adjustment of the degree codes may affect each other, thereby reducing the stability and maintainability of the system; for the second mode, because a general rule engine is introduced, and the general rule engine does not provide targeted support for insurance claims, the current rule engine is mainly used for realizing partial audit rules and simple calculation, and therefore, the second mode has great restrictions on processing efficiency and support comprehensiveness. In addition, in the current process of claim processing, new claim rules may be added, which requires a lot of manual operations, and the manual operations may not effectively improve the claim timeliness, and the results processed by different claim workers may be inconsistent, which may result in a situation where the accuracy of claim processing is low.
In view of this, there is a need for a claim amount determination method, a claim amount determination apparatus, a storage medium, and an electronic device.
It is to be noted that the information disclosed in the above background section is only for enhancement of understanding of the background of the present disclosure, and thus may include information that does not constitute prior art known to those of ordinary skill in the art.
Disclosure of Invention
An object of the present disclosure is to provide a claim amount determining method, a claim amount determining apparatus, a storage medium, and an electronic device, thereby overcoming, at least to some extent, one or more of the problems due to the limitations and disadvantages of the related art.
According to an aspect of the present disclosure, there is provided a claim amount determination method including:
abstracting an claim settlement model based on policy data;
generating a rule engine according to the claim settlement model and by combining a syntax analyzer;
acquiring claim application data; and
the claim application data is processed to determine an amount of the claim based on the claim rules provided by the rules engine.
In an exemplary embodiment of the disclosure, after the acquiring the claim application data, the method for determining a claim amount further includes:
and if the claim rules corresponding to the claim application data comprise the claim rules except the claim rules provided by the rule engine, adding the claim rules except the claim rules provided by the rule engine to the rule engine.
In an exemplary embodiment of the disclosure, after the acquiring the claim application data, the method for determining a claim amount further includes:
and if the claim rules corresponding to the claim application data comprise the claim rules except the claim rules provided by the rule engine, modifying the claim rules provided by the rule engine so as to match the claim rules except the claim rules provided by the rule engine.
In an exemplary embodiment of the disclosure, before the processing the claim application data based on the claim rules provided by the rules engine, the method for determining a claim amount further includes:
and converting the rule script provided by the rule engine into an executable rule object.
In an exemplary embodiment of the disclosure, the processing the claim application data to determine the claim amount based on the claim rules provided by the rules engine comprises:
running a data verification rule to verify the validity of the claim application data;
acquiring policy data corresponding to the claim settlement application data according to the claim settlement application data; wherein the policy data is determined by attribute information of the insurance product and underwriting data;
screening insurance responsibility for claims based on the policy data;
associating the insurance responsibility with a bill and verifying the validity of the bill; and
and calculating the claim amount of the bill as the claim settlement amount.
According to an aspect of the present disclosure, there is provided a claim amount determination apparatus including:
the model abstraction module is used for abstracting the claim settlement model based on the policy data;
the rule engine generating module is used for generating a rule engine according to the claim settlement model and by combining a syntax analyzer;
the claim settlement data acquisition module is used for acquiring claim settlement application data; and
and the claim amount determining module is used for processing the claim application data based on the claim rules provided by the rule engine to determine the claim amount.
In an exemplary embodiment of the present disclosure, the claim amount determining apparatus further includes:
and the first rule processing module is used for adding the claim rules except the claim rules provided by the rule engine to the rule engine if the claim rules corresponding to the claim application data exist in the claim rules except the claim rules provided by the rule engine.
In an exemplary embodiment of the present disclosure, the claim amount determining apparatus further includes:
and the second rule processing module is used for modifying the claim settlement rules provided by the rule engine so as to match the claim settlement rules other than the claim settlement rules provided by the rule engine if the claim settlement rules corresponding to the claim application data exist in the claim settlement rules other than the claim settlement rules provided by the rule engine.
In an exemplary embodiment of the present disclosure, the claim amount determining apparatus further includes:
and the rule conversion module is used for converting the rule script provided by the rule engine into an executable rule object.
In an exemplary embodiment of the disclosure, the claim amount determination module includes:
the claim data verification unit is used for operating a data verification rule so as to verify the validity of the claim application data;
the policy data acquisition unit is used for acquiring policy data corresponding to the claim application data according to the claim application data; wherein the policy data is determined by attribute information of the insurance product and underwriting data;
the insurance policy screening unit is used for screening insurance responsibility of claim settlement based on the insurance policy data;
the bill checking unit is used for associating the insurance responsibility with a bill and checking the validity of the bill;
and the pay amount calculation unit is used for calculating the pay amount of the bill as the claim settlement amount.
According to an aspect of the present disclosure, there is provided a storage medium having stored thereon a computer program which, when executed by a processor, implements the claim amount determination method of any one of the above.
According to an aspect of the present disclosure, there is provided an electronic device including:
a processor; and
a memory for storing executable instructions of the processor;
wherein the processor is configured to perform any of the claims amount determination methods described above via execution of the executable instructions.
In the technical solutions provided by some embodiments of the present disclosure, a claim model is abstracted based on policy data, a rule engine is generated according to the claim model in combination with a parser, and the claim application data is processed based on the rule engine to determine the claim amount, on one hand, a rule engine for exclusive insurance claims can be constructed by abstracting the claim model based on policy data and generating the rule engine according to the claim model in combination with the parser, so that the claim processing efficiency and pertinence are improved; on the other hand, due to the fact that the rule engine is built, the method and the system realize decoupling of the business rules and other system programs, help to quickly build corresponding business rules aiming at new business requirements, do not need to consider influences on other functions of the system in many aspects, and further improve processing efficiency of claim settlement business.
It is to be understood that both the foregoing general description and the following detailed description are exemplary and explanatory only and are not restrictive of the disclosure.
Drawings
The accompanying drawings, which are incorporated in and constitute a part of this specification, illustrate embodiments consistent with the present disclosure and together with the description, serve to explain the principles of the disclosure. It is to be understood that the drawings in the following description are merely exemplary of the disclosure, and that other drawings may be derived from those drawings by one of ordinary skill in the art without the exercise of inventive faculty. In the drawings:
FIG. 1 schematically illustrates a block diagram of a manner of claim processing for some technologies;
FIG. 2 schematically illustrates a flow chart of a claim amount determination method according to an exemplary embodiment of the present disclosure;
FIG. 3 schematically illustrates an architecture diagram of an insurance product model, according to an exemplary embodiment of the present disclosure;
FIG. 4 schematically illustrates an architecture diagram of a claim model, according to an exemplary embodiment of the present disclosure;
FIG. 5 illustrates a schematic diagram of partitioning a policy for some techniques;
FIG. 6 illustrates a schematic diagram of the partitioning of a policy according to an exemplary embodiment of the present disclosure;
FIG. 7 is a schematic diagram illustrating an adjustment to the assurance items of the policy with respect to that shown in FIG. 6;
FIG. 8 schematically illustrates a flow diagram of a rule caching mechanism, according to an exemplary embodiment of the present disclosure;
FIG. 9 schematically illustrates an architecture diagram of a system of model run logic according to an exemplary embodiment of the present disclosure;
FIG. 10 schematically illustrates a block diagram of a claim amount determination apparatus according to an exemplary embodiment of the present disclosure;
FIG. 11 shows a schematic diagram of a storage medium according to an example embodiment of the present disclosure;
FIG. 12 schematically illustrates a block diagram of an electronic device according to an exemplary embodiment of the present disclosure;
13-19 illustrate schematic diagrams of operational interfaces for database deployment for implementing the present disclosure; and
20-28 illustrate schematic views of an operator interface for deployment of an insurance claims system for implementing the present disclosure.
Detailed Description
Example embodiments will now be described more fully with reference to the accompanying drawings. Example embodiments may, however, be embodied in many different forms and should not be construed as limited to the examples set forth herein; rather, these embodiments are provided so that this disclosure will be thorough and complete, and will fully convey the concept of example embodiments to those skilled in the art. The described features, structures, or characteristics may be combined in any suitable manner in one or more embodiments. In the following description, numerous specific details are provided to give a thorough understanding of embodiments of the disclosure. One skilled in the relevant art will recognize, however, that the subject matter of the present disclosure can be practiced without one or more of the specific details, or with other methods, components, devices, steps, and the like. In other instances, well-known technical solutions have not been shown or described in detail to avoid obscuring aspects of the present disclosure.
Furthermore, the drawings are merely schematic illustrations of the present disclosure and are not necessarily drawn to scale. The same reference numerals in the drawings denote the same or similar parts, and thus their repetitive description will be omitted. Some of the block diagrams shown in the figures are functional entities and do not necessarily correspond to physically or logically separate entities. These functional entities may be implemented in the form of software, or in one or more hardware modules or integrated circuits, or in different networks and/or processor devices and/or microcontroller devices.
The flow charts shown in the drawings are merely illustrative and do not necessarily include all of the steps. For example, some steps may be decomposed, and some steps may be combined or partially combined, so that the actual execution sequence may be changed according to the actual situation.
Fig. 2 schematically illustrates a flowchart of a claim amount determination method of an exemplary embodiment of the present disclosure. Referring to fig. 2, the claim amount determination method may include the steps of:
s20, abstracting a claim settlement model based on policy data;
s22, generating a rule engine according to the claim settlement model and by combining a syntax analyzer;
s24, acquiring claim settlement application data; and
s26, processing the claim application data based on the claim rules provided by the rule engine to determine the claim amount.
In the method for determining the claim amount, the claim model is abstracted based on the policy data, the rule engine is generated according to the claim model and by combining the syntactic analyzer, and the claim application data is processed based on the rule engine to determine the claim amount, on one hand, the rule engine for exclusive insurance claim can be constructed by abstracting the claim model based on the policy data and generating the rule engine according to the claim model and by combining the syntactic analyzer, so that the claim processing efficiency and pertinence are improved; on the other hand, due to the fact that the rule engine is built, the method and the system realize decoupling of the business rules and other system programs, help to quickly build corresponding business rules aiming at new business requirements, do not need to consider influences on other functions of the system in many aspects, and further improve processing efficiency of claim settlement business.
The respective steps of the claim amount determining method of the exemplary embodiment of the present disclosure will be explained below.
In step S20, the claims model is abstracted based on the policy data.
In an exemplary embodiment of the present disclosure, the indicators corresponding to the policy data may include, but are not limited to: name of insurance product, risk category, responsibility, party information (insurance company, applicant, insured person), claim settlement, etc.
First, the server may obtain policy data, wherein the policy data may be stored in a storage space dedicated to storing policy data, and additionally, the policy data may be stored in storage spaces corresponding to the application data, respectively.
Subsequently, the server may extract data of target indexes from the policy data, where the target indexes may be all or part of the indexes of the policy data, and may specifically determine the target indexes according to the claim settlement items, that is, the claim settlement items are different, and the determined target indexes may have differences.
Next, the server may abstract an claim model using the data of the target index extracted from the policy data. For example, the claim settlement model may be abstracted by using a machine learning method, specifically, the extracted data of the target index may be trained and learned, and the specific process of machine learning is not particularly limited in the present disclosure.
In addition, the disclosure can include abstracting policy data into various metrics, and by establishing associations between metrics, enabling the definition of insurance products and claim structures. In addition, various business logic, audit rules and calculation rule definitions can be realized through the rules, so that the structure of the system, products and the rules is realized.
In addition, the claims models described in this disclosure can include models built for insurance products and models built for claims. Fig. 3 and 4 show, by way of example, an architecture diagram of an insurance product model and an claims model, respectively, as determined by the present disclosure.
Referring to fig. 3, an insurance company 301 may be corresponding to an insurance product 302, the insurance product 302 may include an insurance seed 303, a responsibility 304, an claim settlement structure 305, and extension information 311, the responsibility 304 may include a payment responsibility 306, a quota responsibility 307, and a public guarantee responsibility 308, and the insurance product 302, the responsibility 304, and the claim settlement structure 305 may further correspond to a rule group 309, and the rule group 309 may correspond to a rule 310, and in addition, the extension information 311 may be composed of a dynamic attribute 312, a form 313, and a two-dimensional table 314.
Referring to fig. 4, the claim model may mainly refer to a claim 401 and related information thereof, and specifically, the claim 401 may correspond to a bill 402, a medical record 404, a disease severity 405, and claim information 406, wherein the bill 402 and the disease severity 405 may further correspond to a fee detail 403, the bill 402 may correspond to the claim information 406, and the claim information 406 and the claim 401 may further correspond to the claim detail 407. In addition, the medical record 404 may further include a rule group 408 and extension information 410, where the rule group 408 may correspond to a rule 409, and the extension information 410 may correspond to a dynamic attribute 411 and a dynamic table 412.
It should be understood that the insurance product models and claim models shown in fig. 3 and 4 are exemplary only, and should not be taken as limiting the present disclosure.
In step S22, a rules engine is generated based on the claim model in conjunction with a parser.
In an exemplary embodiment of the present disclosure, the parser may be, for example, an open source parser of Antlr. However, the parser may also be other existing parsers, and the disclosure is not limited in this regard. And based on the Antlr, the rule grammar of the insurance system can be constructed, and the rule grammar is simple so as to facilitate the learning of business personnel. The grammar rules constructed by the grammar analyzer Antlr in combination with the claim model abstracted in step S20 can provide the operation grammar and extended service functions related to the claim model, and compared with the traditional rule engine, the present disclosure can provide richer grammar and built-in service.
The present disclosure can generate a rules engine from the claims model in conjunction with a parser, which can support some basic syntax and built-in services.
In particular, the basic syntax may include, but is not limited to, syntax examples, data types, comments, variable definitions, array operations, Map operations, ifelsel conditional syntax, While loops, string functions (intercept, find, split), numeric functions (round, numeric to integer, string to numeric), date functions, element attribute operations, element path operations, dictionary (parameter) access, method calls, object operations, health care trinocular billing items syntax, medical diagnosis operations syntax, hospital data operations syntax, call rules, termination rules, and the like. Built-in services may include, but are not limited to, obtaining information on the policy, matching insurance responsibility, associating bills, adding account groups, clearing unwanted bills and responsibility, excluding from charge items, setting bill cost information based on responsibility for payment, charging item aggregation, accounting pre-processing rules, pay-as-you-go processing, proportion of claims, limit processing, processing of public insurance, setting and apportioning amounts of responsibility claims to bills, rules of responsibility claim accumulation, general cumulative storage, general cumulative acquisition, and the like.
Further, the rules engine generated from the claims model in conjunction with the parser may include the following functions: interface rule configuration, rule grammar configuration, rule operation test, rule grouping management, and support of a large number of calculation rules and audit rules.
In step S24, claim application data is acquired.
In an exemplary embodiment of the present disclosure, the server may obtain the claim settlement application data from the insurance service end, where the insurance service end may include a computer terminal of each insurance service site, an insurance service network interface port, and the like. In addition, the claim application data can include information such as medical records, claim items, claim time, bills and the like. In addition, the server may determine the claim rule corresponding to the claim application data, and specifically, may determine whether the claim rule corresponding to the claim application data is included in the claim rule provided by the rule engine determined in step S22.
According to some embodiments of the disclosure, if a claim rule other than the claim rule provided by the rule engine exists in the claim rule corresponding to the claim application data, the claim rule can be added to the rule engine.
According to other embodiments, if the claim rules corresponding to the claim application data include claim rules other than the claim rules provided by the rules engine, the claim rules provided by the rules engine may be modified, so that the modified claim rules can be matched with the claim rules other than the principle claim rules provided by the rules engine.
Fig. 5 illustrates a schematic diagram of partitioning a policy for some techniques. The policy 50 may correspond to the claim items 51 corresponding to free, limit, and public insurance, and the policy 50 may be hierarchically divided, that is, the policy 50 includes a plan 501, the plan 501 includes an insurance type 502, the insurance type 502 includes a responsibility 503, and the responsibility 503 includes a pay responsibility 504, wherein the plan 501, the insurance type 502, the responsibility 503, and the pay responsibility 504 may correspond to the claim items 511, 512, 513, 514 corresponding to free, limit, and public insurance, respectively.
Fig. 6 shows a schematic diagram of the division of a policy according to an exemplary embodiment of the present disclosure. Unlike some of the techniques described in FIG. 5, levels 61 and 62 may be added between policy 60 and plan 63, and responsibility groups 65 may be added between risk classes 64 and responsibilities 66. The added hierarchy is helpful for solving the condition that corresponding rules need to be supplemented due to special convention during insurance support, and the requirements of customers are met. In addition, the architecture exemplarily shown in fig. 6 of the present disclosure supports definition of arbitrary hierarchy and definition of responsibility group, and insurance requirements can be more flexibly defined. For example, if only a policy level is required, only the policy level definition is required, so that all responsibilities under the policy are affected by the contract.
FIG. 7 is a schematic diagram illustrating an adjustment to the assurance items of the policy with respect to FIG. 6. Specifically, the items of exemption, quota and public allowance can be changed into hospital, disease and medical items. It should be understood that the above-mentioned security program is only exemplary, for example, the security program may also include appointments for medical related content, such as hospital levels, regions, disease ranges, medication restrictions, etc., and the disclosure is not limited thereto.
In step S26, the claim application data is processed to determine the claim amount based on the claim rules provided by the rules engine.
According to some embodiments of the present disclosure, prior to processing the claims application data, the present disclosure further provides a rule caching mechanism that specifically includes converting a rule script provided by a rule engine into an executable rule object. The rule caching mechanism of the present disclosure is explained with reference to fig. 8. In step S801, the claim settlement system may be started; in step S803, the corresponding rule may be read from the rule engine; in step S805, all involved rule scripts may be compiled and converted into executable rule objects; in step S807, the compiled rule object may be placed in a cache; in step S809, the claim service can be started and corresponding rules can be extracted from the cache for a specific claim calculation process.
Through the rule caching mechanism, the process of analyzing during execution is avoided, and therefore the execution efficiency of the rule is improved.
In an exemplary embodiment of the disclosure, after the server obtains the claim application data, the server may disassemble the claim application data based on insurance terms provided by an insurance company and/or an insurance agreement of a client, and correspond the disassembled data to the model determined in step S20, and perform configuration of corresponding rules, such as hospital level restriction, claim amount exemption control, and the like. These data can then be processed based on the generated rules engine to determine the claim amount corresponding to the claim application data.
Specifically, first, a data verification rule may be run to verify validity of the claim application data; then, acquiring policy data corresponding to the claim application data according to the claim application data, wherein the policy data can be determined by the attribute information and underwriting data of the insurance product; next, insurance responsibilities for claims may be screened based on policy data; then, the insurance responsibility can be associated with the bill, and the validity of the bill can be verified, specifically, the validity of the bill can be automatically verified based on the conditions of diagnosis, hospitals, bill days and the like; then, the paying amount of the bill can be calculated, and specifically, the paying amount of the corresponding bill can be automatically calculated according to the definition information of insurance responsibility, definition of insurance products, exemption, limit, hospital, diagnosis and the like. In addition, the calculated claims and payment amounts can be collected to determine the claim amount corresponding to the claim application data.
FIG. 9 schematically illustrates an architecture diagram of a model run logic system according to an exemplary embodiment of the present disclosure. Referring to fig. 9, the model operating logic system of the present disclosure may include an insurance product definition module 91, an insurance policy module 92, a rules engine 93, an claims settlement module 94, a hospital data module 95, a medical insurance catalog module 96, and a diagnostic module 97. The claim settlement module 94 may include a claim settlement basic information module 941, a billing module 942, a prescription module 943, a medical record module 944, a claim payment information module 945, and an audit information module 946. Specifically, the rules engine 93 may interact with the insurance product definition module 91, the policy module 92, the hospital data module 95, the medical insurance directory module 96, and the diagnosis module 97, respectively, and the claims settlement module 94 may interact with the rules engine 93. It should be understood that the system architecture shown in fig. 9 is merely exemplary, and various modules related to implementing the method for determining a claim amount described in the present disclosure are all contemplated by the present invention.
Because some group insurance adjustment rules are complex, the prior art can not completely decouple the business rules and the back-end system, so that once a scene which can not be met by the prior system appears, research and development resources are required to be introduced to carry out a series of work such as long-time demand analysis, development, testing and the like, the consumed time is long, and the business demand can not be met quickly. At present, the automatic settlement rate of the group insurance can only reach about 50%, and the automatic settlement rate can be improved to more than 90% by adopting the method, so that the operating cost of health insurance settlement is greatly reduced, and the efficiency is improved. In addition, the scheme of the disclosure can be combined with products such as sales, underwriting and the like, and can provide an overall solution for customers.
It should be noted that although the various steps of the methods of the present disclosure are depicted in the drawings in a particular order, this does not require or imply that these steps must be performed in this particular order, or that all of the depicted steps must be performed, to achieve desirable results. Additionally or alternatively, certain steps may be omitted, multiple steps combined into one step execution, and/or one step broken down into multiple step executions, etc.
Further, the present exemplary embodiment also provides a claim amount determination apparatus.
Fig. 10 schematically shows a block diagram of the claim amount determination apparatus of the exemplary embodiment of the present disclosure. Referring to fig. 10, the claim amount determining apparatus 10 according to an exemplary embodiment of the present disclosure may include a model abstraction module 101, a rule engine generation module 103, a claim data acquisition module 105, and a claim amount determining module 107, wherein:
the model abstraction module 101 can be used for abstracting the claim settlement model based on the policy data;
a rule engine generating module 103, configured to generate a rule engine according to the claim model and in combination with a parser;
the claim settlement data acquisition module 105 may be configured to acquire claim settlement application data; and
the claim amount determination module 107 can be configured to process the claim application data based on the claim rules provided by the rules engine to determine the claim amount.
In the claim amount determination device disclosed by the disclosure, on one hand, the rule engine for exclusive insurance claims can be constructed by abstracting the claim model based on the policy data and generating the rule engine according to the claim model and combining the syntax analyzer, so that the claim processing efficiency and pertinence are improved; on the other hand, due to the fact that the rule engine is built, the method and the system realize decoupling of the business rules and other system programs, help to quickly build corresponding business rules aiming at new business requirements, do not need to consider influences on other functions of the system in many aspects, and further improve processing efficiency of claim settlement business.
According to an exemplary embodiment of the present disclosure, the claim amount determination apparatus 10 may further include a first rule processing module, wherein:
the first rule processing module may be configured to add, to the rule engine, a claim rule other than the claim rule provided by the rule engine if the claim rule corresponding to the claim application data includes a claim rule other than the claim rule provided by the rule engine.
In the present exemplary embodiment, the calculation of the specially agreed claims amount may be achieved by adding rules.
According to an exemplary embodiment of the present disclosure, the claim amount determination apparatus 10 may further include a second rule processing module, wherein:
the second rule processing module may be configured to modify the claim rules provided by the rule engine to match the claim rules other than the claim rules provided by the rule engine if the claim rules corresponding to the claim application data include claim rules other than the claim rules provided by the rule engine.
In the present exemplary embodiment, the calculation of the specially agreed claims amount may be achieved by modifying the rules.
According to an exemplary embodiment of the present disclosure, the claim amount determination apparatus 10 may further include a rule conversion module, wherein:
a rule conversion module, which can be used to convert the rule script provided by the rule engine into an executable rule object.
In the exemplary embodiment, the process of rule analysis in the process of claim settlement execution is avoided, and the rule execution efficiency is improved.
According to an exemplary embodiment of the present disclosure, the claim amount determination module 107 may include a claim data verification unit, an insurance policy data acquisition unit, an insurance policy screening unit, a bill verification unit, and a claim amount calculation unit, wherein:
the claim data verification unit can be used for operating a data verification rule so as to verify the validity of the claim application data;
the policy data acquisition unit can be used for acquiring policy data corresponding to the claim application data according to the claim application data; wherein the policy data is determined by attribute information of the insurance product and underwriting data;
an insurance policy screening unit operable to screen insurance responsibilities for claims based on the insurance policy data;
the bill checking unit can be used for associating the insurance responsibility with a bill and checking the validity of the bill;
and the dividend amount calculation unit can be used for calculating the dividend amount of the bill as the claim amount.
In the present exemplary embodiment, an exemplary process for calculating an amount to be claimed by a rules engine is disclosed.
Since each functional module of the program operation performance analysis apparatus according to the embodiment of the present invention is the same as that in the embodiment of the present invention, it is not described herein again.
In an exemplary embodiment of the present disclosure, there is also provided a computer-readable storage medium having stored thereon a program product capable of implementing the above-described method of the present specification. In some possible embodiments, aspects of the invention may also be implemented in the form of a program product comprising program code means for causing a terminal device to carry out the steps according to various exemplary embodiments of the invention described in the above section "exemplary methods" of the present description, when said program product is run on the terminal device.
Referring to fig. 11, a program product 1100 for implementing the above method according to an embodiment of the present invention is described, which may employ a portable compact disc read only memory (CD-ROM) and include program code, and may be run on a terminal device, such as a personal computer. However, the program product of the present invention is not limited in this regard and, in the present document, a readable storage medium may be any tangible medium that can contain, or store a program for use by or in connection with an instruction execution system, apparatus, or device.
The program product may employ any combination of one or more readable media. The readable medium may be a readable signal medium or a readable storage medium. A readable storage medium may be, for example, but not limited to, an electronic, magnetic, optical, electromagnetic, infrared, or semiconductor system, apparatus, or device, or any combination of the foregoing. More specific examples (a non-exhaustive list) of the readable storage medium include: an electrical connection having one or more wires, a portable disk, a hard disk, a Random Access Memory (RAM), a read-only memory (ROM), an erasable programmable read-only memory (EPROM or flash memory), an optical fiber, a portable compact disc read-only memory (CD-ROM), an optical storage device, a magnetic storage device, or any suitable combination of the foregoing.
A computer readable signal medium may include a propagated data signal with readable program code embodied therein, for example, in baseband or as part of a carrier wave. Such a propagated data signal may take many forms, including, but not limited to, electro-magnetic, optical, or any suitable combination thereof. A readable signal medium may also be any readable medium that is not a readable storage medium and that can communicate, propagate, or transport a program for use by or in connection with an instruction execution system, apparatus, or device.
Program code embodied on a readable medium may be transmitted using any appropriate medium, including but not limited to wireless, wireline, optical fiber cable, RF, etc., or any suitable combination of the foregoing.
Program code for carrying out operations for aspects of the present invention may be written in any combination of one or more programming languages, including an object oriented programming language such as Java, C + + or the like and conventional procedural programming languages, such as the "C" programming language or similar programming languages. The program code may execute entirely on the user's computing device, partly on the user's device, as a stand-alone software package, partly on the user's computing device and partly on a remote computing device, or entirely on the remote computing device or server. In the case of a remote computing device, the remote computing device may be connected to the user computing device through any kind of network, including a Local Area Network (LAN) or a Wide Area Network (WAN), or may be connected to an external computing device (e.g., through the internet using an internet service provider).
In an exemplary embodiment of the present disclosure, an electronic device capable of implementing the above method is also provided.
As will be appreciated by one skilled in the art, aspects of the present invention may be embodied as a system, method or program product. Thus, various aspects of the invention may be embodied in the form of: an entirely hardware embodiment, an entirely software embodiment (including firmware, microcode, etc.) or an embodiment combining hardware and software aspects that may all generally be referred to herein as a "circuit," module "or" system.
An electronic device 1200 according to this embodiment of the invention is described below with reference to fig. 12. The electronic device 1200 shown in fig. 12 is only an example, and should not bring any limitation to the functions and the scope of use of the embodiments of the present invention.
As shown in fig. 12, the electronic device 1200 is embodied in the form of a general purpose computing device. The components of the electronic device 1200 may include, but are not limited to: the at least one processing unit 1210, the at least one memory unit 1220, the bus 1230 connecting the various system components (including the memory unit 1220 and the processing unit 1210), and the display unit 1240.
Wherein the memory unit stores program code that is executable by the processing unit 1210 such that the processing unit 1210 performs steps according to various exemplary embodiments of the present invention as described in the above section "exemplary methods" of the present specification. For example, the processing unit 1210 may perform step S20 as shown in fig. 2: abstracting an claim settlement model based on policy data; step S22: generating a rule engine according to the claim settlement model and by combining a syntax analyzer; step S24: acquiring claim application data; and step S26: the claim application data is processed to determine an amount of the claim based on the claim rules provided by the rules engine.
The storage unit 1220 may include a readable medium in the form of a volatile memory unit, such as a random access memory unit (RAM)12201 and/or a cache memory unit 12202, and may further include a read only memory unit (ROM) 12203.
The electronic device 1200 may also communicate with one or more external devices 1300 (e.g., keyboard, pointing device, bluetooth device, etc.), with one or more devices that enable a user to interact with the electronic device 1200, and/or with any devices (e.g., router, modem, etc.) that enable the electronic device 1200 to communicate with one or more other computing devices. Such communication may occur via input/output (I/O) interfaces 1250. Also, the electronic device 1200 may communicate with one or more networks (e.g., a Local Area Network (LAN), a Wide Area Network (WAN), and/or a public network such as the Internet) via the network adapter 1260. As shown, the network adapter 1260 communicates with the other modules of the electronic device 1200 via the bus 1230. It should be appreciated that although not shown, other hardware and/or software modules may be used in conjunction with the electronic device 1200, including but not limited to: microcode, device drivers, redundant processing units, external disk drive arrays, RAID systems, tape drives, and data backup storage systems, among others.
Through the above description of the embodiments, those skilled in the art will readily understand that the exemplary embodiments described herein may be implemented by software, or by software in combination with necessary hardware. Therefore, the technical solution according to the embodiments of the present disclosure may be embodied in the form of a software product, which may be stored in a non-volatile storage medium (which may be a CD-ROM, a usb disk, a removable hard disk, etc.) or on a network, and includes several instructions to enable a computing device (which may be a personal computer, a server, a terminal device, or a network device, etc.) to execute the method according to the embodiments of the present disclosure.
Further, fig. 13 to 19 are schematic diagrams illustrating an operation interface for database deployment to implement the disclosure. In addition, fig. 20-28 show schematic views of an operator interface for deployment of an insurance claims system for implementing the present disclosure.
Furthermore, the above-described figures are merely schematic illustrations of processes involved in methods according to exemplary embodiments of the invention, and are not intended to be limiting. It will be readily understood that the processes shown in the above figures are not intended to indicate or limit the chronological order of the processes. In addition, it is also readily understood that these processes may be performed synchronously or asynchronously, e.g., in multiple modules.
It should be noted that although in the above detailed description several modules or units of the device for action execution are mentioned, such a division is not mandatory. Indeed, the features and functionality of two or more modules or units described above may be embodied in one module or unit, according to embodiments of the present disclosure. Conversely, the features and functions of one module or unit described above may be further divided into embodiments by a plurality of modules or units.
Other embodiments of the disclosure will be apparent to those skilled in the art from consideration of the specification and practice of the disclosure disclosed herein. This application is intended to cover any variations, uses, or adaptations of the disclosure following, in general, the principles of the disclosure and including such departures from the present disclosure as come within known or customary practice within the art to which the disclosure pertains. It is intended that the specification and examples be considered as exemplary only, with a true scope and spirit of the disclosure being indicated by the following claims.
It will be understood that the present disclosure is not limited to the precise arrangements described above and shown in the drawings and that various modifications and changes may be made without departing from the scope thereof. The scope of the present disclosure is to be limited only by the terms of the appended claims.
Claims (4)
1. A method of claim amount determination, comprising:
acquiring policy data, extracting target index data from the policy data, and abstracting an insurance model based on the target index data, wherein the insurance model comprises a model constructed for insurance products and a model constructed for claims, the model constructed for insurance products comprises a first insurance product level, a second insurance product level and a third insurance product level, the first insurance product level is insurance products corresponding to insurance companies, the second insurance product level is insurance seeds, responsibility products, claim settlement results and expansion information corresponding to the insurance products, the third insurance product level is payment responsibility, limit responsibility and public insurance responsibility corresponding to the responsibility, the model constructed for claims comprises a first claim level and a second claim level, the first claim level is claims, and the second claim level is bills, statements, claims, statements and expansion information corresponding to the claims, Medical history, serious illness, and claim information;
generating a rule engine according to the claim settlement model and by combining a syntax analyzer, wherein the rule engine comprises a preset syntax and a built-in service;
acquiring claim application data; and
processing the claim application data based on claim settlement rules provided by the rules engine to determine a claim amount;
if the claim rules corresponding to the claim application data comprise claim rules other than the claim rules provided by the rules engine, adding the claim rules other than the claim rules provided by the rules engine to the rules engine; or modifying the claim rules provided by the rule engine so as to match the claim rules except the claim rules provided by the rule engine;
before the processing the claim application data based on the claim rules provided by the rules engine, the method for determining the claim amount further comprises:
starting a claim settlement system;
reading corresponding rules from the rule engine;
compiling and converting all related rule scripts into executable rule objects;
putting the compiled rule object into a cache;
opening a claim settlement service, extracting corresponding rules from the cache, and executing the step of processing the claim settlement application data based on the claim settlement rules provided by the rule engine to determine the claim amount;
the processing the claim application data to determine a claim amount based on the claim rules provided by the rules engine comprises:
running a data verification rule to verify the validity of the claim application data;
acquiring policy data corresponding to the claim settlement application data according to the claim settlement application data; wherein the policy data is determined by attribute information of the insurance product and underwriting data;
screening insurance responsibility for claims based on the policy data;
associating the insurance responsibility with a bill and verifying the validity of the bill; and
and calculating the claim amount of the bill as the claim settlement amount.
2. An claim amount determination apparatus, comprising:
the model abstraction module is used for acquiring policy data, extracting target index data from the policy data, and abstracting a claim settlement model based on the target index data, wherein the claim settlement model comprises a model constructed for insurance products and a model constructed for claims, the model constructed for insurance products comprises a first insurance product level, a second insurance product level and a third insurance product level, the first insurance product level is an insurance product corresponding to an insurance company, the second insurance product level is an insurance seed, a responsibility, a claim settlement result and expansion information corresponding to the insurance product, the third insurance product level is a payment responsibility, a limit responsibility and a public insurance amount corresponding to the responsibility, the model constructed for claims comprises a first claim level and a second claim settlement level, the first claim level is a claim, and the second claim settlement level is a bill corresponding to the claim, Medical history, serious illness, and claim information;
the rule engine generating module is used for generating a rule engine according to the claim settlement model and by combining a syntax analyzer;
the claim settlement data acquisition module is used for acquiring claim settlement application data; and
the claim settlement amount determining module is used for processing the claim settlement application data based on the claim settlement rules provided by the rule engine to determine the claim settlement amount;
the first rule processing module is used for adding the claim rules except the claim rules provided by the rule engine to the rule engine if the claim rules corresponding to the claim application data have the claim rules except the claim rules provided by the rule engine; alternatively, the first and second electrodes may be,
the second rule processing module is used for modifying the claim settlement rules provided by the rule engine if the claim settlement rules corresponding to the claim application data have the claim settlement rules except the claim settlement rules provided by the rule engine so as to match the claim settlement rules except the claim settlement rules provided by the rule engine;
before the processing of the claim application data based on the claim rules provided by the rules engine, the claim amount determination device is further configured to:
starting a claim settlement system;
reading corresponding rules from the rule engine;
compiling and converting all related rule scripts into executable rule objects;
putting the compiled rule object into a cache;
opening a claim settlement service, extracting corresponding rules from the cache, and executing the step of processing the claim settlement application data based on the claim settlement rules provided by the rule engine to determine the claim amount;
the claim amount determination module is configured to:
running a data verification rule to verify the validity of the claim application data;
acquiring policy data corresponding to the claim settlement application data according to the claim settlement application data; wherein the policy data is determined by attribute information of the insurance product and underwriting data;
screening insurance responsibility for claims based on the policy data;
associating the insurance responsibility with a bill and verifying the validity of the bill; and
and calculating the claim amount of the bill as the claim settlement amount.
3. A storage medium on which a computer program is stored, the computer program realizing the claim amount determination method of claim 1 when executed by a processor.
4. An electronic device, comprising:
a processor; and
a memory for storing executable instructions of the processor;
wherein the processor is configured to perform the claim amount determination method of claim 1 via execution of the executable instructions.
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| CN109255718A (en) * | 2018-06-28 | 2019-01-22 | 平安科技（深圳）有限公司 | Insurance benefits method and apparatus, computer equipment and readable storage medium storing program for executing |
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| CN109360113B (en) * | 2018-12-14 | 2021-04-13 | 泰康保险集团股份有限公司 | Automatic policy adjustment method, device, medium and electronic equipment |
| CN109636655A (en) * | 2018-12-26 | 2019-04-16 | 上海百事通信息技术股份有限公司 | A kind of car insurance Claims Resolution computing system and self-aided terminal |
| CN111524017B (en) * | 2019-02-01 | 2023-09-22 | 北京懿医云科技有限公司 | Method, device and medium for auditing of claim data |
| CN110517155A (en) * | 2019-08-02 | 2019-11-29 | 中国人寿保险股份有限公司 | A kind of medical insurance compensates automatic accounting method and system |
| CN111027984B (en) * | 2019-11-20 | 2023-08-04 | 上海携程国际旅行社有限公司 | Service order processing method, system, electronic equipment and computer storage medium |
| CN111428132B (en) * | 2020-03-18 | 2023-09-19 | 腾讯科技（深圳）有限公司 | Data verification method and device, computer storage medium and electronic equipment |
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