CN109636085A - Based on the pre-authorization of data processing from kernel method and system - Google Patents
Based on the pre-authorization of data processing from kernel method and system Download PDFInfo
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Abstract
This disclosure relates to it is a kind of based on the pre-authorization of data processing from kernel method and system, it the described method comprises the following steps: 1, receiving from insured people for the pre-authorization application settled a claim, the pre-authorization application includes the personal information of the insured people and the medical information of the insured people；2, according to the medical information of the insured people, settling fee relevant to the pre-authorization application is calculated；3, according to the personal information of the insured people and the medical information of the insured people, the characteristic information of insured people is further obtained from medical big data；4, according to the characteristic information of the insured people obtained in step 3, determine the risk class of the insured people；5, according to the risk class of the insured people and settling fee relevant to the pre-authorization application, judge in the pre-authorization application that whether doubtful there are not firm information；If 6, the judging result in step 5 is "Yes", turn by background process.
Description
Technical field
The present invention relates to insurance service technical fields based on Internet application more particularly to a kind of based on data processing
Pre-authorization is from kernel method and system.
Background technique
Currently, all clients are directed to the pre-authorization application case of medical insurance claims, and it is all manual examination and verification judgement, error-prone, effect
Rate is low, is unfavorable for the processing of pre-authorization case.By calling application, client needs to be identified multinomial identity information, time for communication
Long, customer satisfaction is low.
Summary of the invention
Accordingly, there exist exploitation needs of the pre-authorization system from kernel function, for for part, Claims Resolution case can be direct afterwards
It winds up the case from core, improves processing and reply efficiency；And declaration form validity may be implemented and manage automatically, and prompt is made to multiclass situation:
If remaining protection amount is insufficient, there is refusal Claims Resolution/authority record to remind, be related to blacklist early warning, saves change from damage and such as subtract in guarantor's processing in advance
It is alert etc., to improve audit accuracy.
In view of the above problem of the prior art, inventor is made that the present invention, utilizes information and multidimensional analysis technology,
In conjunction with insurance data, Claims Resolution managerial knowledge, disease and diagnosis and treatment grouping information, provided not for health insurance Claims Resolution with administration office of the hospital
With angle, flexible self-service analysis platform.
According to an embodiment of the invention, provide it is a kind of based on the pre-authorization of data processing from kernel method, be applied to doctor
Treat insurance institution, which is characterized in that the described method comprises the following steps:
Step 1 receives the pre-authorization application for Claims Resolution from insured people, and the pre-authorization application includes the insured people
The medical information of personal information and the insured people；
Step 2, according to the medical information of the insured people, calculate settling fee relevant to the pre-authorization application；
Step 3, according to the personal information of the insured people and the medical information of the insured people, further from medical treatment
The characteristic information of insured people is obtained in big data；
The characteristic information for the insured people that step 4, basis obtain in step 3, determines the levels of risk of the insured people
Not；
Step 5, the risk class according to the insured people and settling fee relevant to the pre-authorization application, sentence
Breaking in the pre-authorization application, whether doubtful there are not firm information；
If the judging result in step 6, step 5 is "Yes", turn by background process.
According to an embodiment of the invention, the medical information of the insured people includes insured people's state of an illness, medical services title, controls
The expense for the treatment of project, Medicines and consumptive material title, corresponding each treatment project.
According to an embodiment of the invention, wherein, the characteristic information includes: the demographic characteristics of the insured people, geography
Feature, medical act temporal characteristics, medical act geographical feature, medical act fee properties.
According to an embodiment of the invention, in step 4, according to the characteristic information of the insured people, by the insured people's
Risk class be divided into "high", " in ", " low " three-level.
According to an embodiment of the invention, in steps of 5:
If the risk class of insured people is "high" and the settling fee be more than with risk class is that "high" is corresponding
First threshold, then judge that doubtful in the pre-authorization application there are not firm information；
If the risk class of insured people be " in " and the settling fee be more than with risk class be " in " it is corresponding
Second threshold, then judge that doubtful in the pre-authorization application there are not firm information.
According to an embodiment of the invention, it is described based on the pre-authorization of data processing from kernel method further include:
If the judging result in step 7, step 5 is "No", inquires and whether needs to check other information,
Step 8, if you do not need to normal after verification other information or the other information are being checked, then by pre-granted
The result of Quan Zihe is determined as " passing through ".
According to an embodiment of the invention, the first threshold is third quartile, the second threshold is the seven or eight point
Digit.
According to an embodiment of the invention, determining the first threshold and the second threshold as follows:
Step S410, outlier Max=(IQR Upper-IQR Lower) * 2+IQR Upper is calculated, wherein IQR
Upper indicates the third quartile in the expense section of the statistical data of risk class, and IQR Lower indicates the risk class
Expense section first quartile；
Step S420, the first threshold is determined as n*Max, the second threshold is determined as m*Max, and wherein n, m are
Coefficient between 1~3, and n > m.
According to an embodiment of the invention, additionally provide a kind of pre-authorization used to perform the method from core system, it is special
Sign is
Pre-authorization application receiving module, for receiving the pre-authorization application for Claims Resolution, the pre-authorization Shen from insured people
It please include the personal information of the insured people and the medical information of the insured people；
Pre-authorization expense computing module, for calculating settling fee relevant to the pre-authorization application；
Insured people's feature obtains module, for according to the personal information of the insured people and the medical treatment of the insured people
Information further obtains the characteristic information of insured people from medical big data；
Risk of fraud determination module determines the levels of risk of the insured people for the characteristic information according to the insured people
Not, and according to the risk class of the insured people and settling fee relevant to the pre-authorization application, judge the pre-granted
Whether doubtful there are not firm information in power application；
Pre-authorization, if the judging result for the risk of fraud determination module is "Yes", turns from core processing module
By background process.
According to an embodiment of the invention, a kind of computer readable storage medium is additionally provided, the computer-readable storage
The program for the above method is stored on medium, when described program is executed by processor, the step of execution according to the method.
Beneficial effects of the present invention essentially consist in that:
1, client's pre-authorization application convenience is improved；From core wind up the case part improve processing reply efficiency；Increase from core early warning and examines
Core accuracy.
2, client can whenever and wherever possible, and directly autonomous online application pre-authorization reduces cumbersome identity validation movement, shortens
Apply for duration, increases customer satisfaction degree；
Detailed description of the invention
Fig. 1 and 2 is to show the pre-authorization of embodiment according to the present invention from the flow diagram of kernel method；
Fig. 3 is the functional block diagram according to the pre-authorization of the embodiment of the present invention from core system；
Fig. 4 is the schematic diagram according to the running environment of the system for being mounted with application program of the embodiment of the present invention.
Specific embodiment
In the following, being described in further detail in conjunction with attached drawing to the implementation of technical solution.
It will be appreciated by those of skill in the art that although the following description is related to many of embodiment for the present invention
Technical detail, but be only for not meaning that any restrictions for illustrating the example of the principle of the present invention.The present invention can be applicable in
In the occasion being different from except technical detail exemplified below, without departing from the principle and spirit of the invention.
It, may be to can be in description in the present specification in addition, tedious in order to avoid being limited to the description of this specification
The portion of techniques details obtained in prior art data has carried out the processing such as omission, simplification, accommodation, this technology for this field
It will be understood by for personnel, and this will not influence the open adequacy of this specification.
Hereinafter, description is used to carry out the embodiment of the present invention.Note that by description is provided with following order: 1, sending out
The summary of bright design；2, pre-authorization is from kernel method (Fig. 1 and 2)；3, pre-authorization is from core system (Fig. 3)；4, reality according to the present invention
Apply the system (Fig. 4) for being mounted with application program of example.
1, the summary of inventive concept
By means of the present invention, creation system forms partial automation from the corresponding relationship of epipole and decision type
From core rule, also, according to pre-authorization cost information, in conjunction with medical big data, whether the application information of the insured people of comprehensive judgement
Wrong (whether having a possibility that not firm informing/fraud).
In this way, by the way that previous cumbersome and inconvenient manual examination and verification process is converted to specifically from epipole, pre-authorization system meeting
Data are obtained from unified lane database verify from core, and these data are by corresponding system module (such as contract in database
About, save from damage, settle a claim) write-in, greatly improve working efficiency and accuracy.
In the following, in conjunction with the embodiments come illustrate foregoing invention design realization.
2, pre-authorization is from kernel method
As shown in Figure 1, the embodiment provides a kind of pre-authorizations from kernel method, the method includes following steps
It is rapid:
Step S100, the pre-authorization application for Claims Resolution is received from insured people, the pre-authorization application includes described insured
The medical information of the personal information of people and the insured people；
Wherein, the pre-authorization application mainly includes insured people's information, insured people's state of an illness, medical services title, treatment item
Mesh, Medicines and consumptive material title, the expense of corresponding each treatment project, etc.；
Step S200, according to the medical information of the insured people, settling fee relevant to the pre-authorization application is calculated.
Step S300, it according to the personal information of the insured people and the medical information of the insured people, further takes up a job as a doctor
Treat the characteristic information that insured people is obtained in big data.
Wherein, the characteristic information is the feature of each dimension of insured people, comprising:
Can directly from available data derived feature, as demographic characteristics, geographical feature, temporal characteristics (as it is medical when
Between, medical interphase, insured time etc.), medical characteristics (such as diagnosis, accurate visit, Medical Consumption inventory, medical institutions' scale, cure
Treat mechanism grade, medical institutions' the past criminal record label, doctor academic title etc.), fee properties (being spent as medical every time), etc.；
Medical frequency (in 1 year), point of medical expenditure at any time by calculating the secondary data obtained, such as clients
Cloth, period always spend, expenditure pattern ratio, etc..
Step S400, according to the characteristic information of the insured people obtained in step S300, determine the risk class of insured people,
And the pre-authorization required cost that obtains in step s 200 is combined, judge whether insured people is doubtful " not firm informing " (that is, it is judged that institute
It states in pre-authorization application with the presence or absence of not firm information)；
Wherein, a possibility that described " not firm informing ", is related to the risk class of insured people and pre-authorization required cost, ginseng
The risk class of guarantor is higher, pre-authorization required cost is higher (irrelevance with critical field), then " the not firm informing "
Possibility is higher.
Wherein, the risk class of the insured people depends on the characteristic information of the insured people, that is, depends on described insured
The medical behavioural information of the static information and history of people, for example, with the age of the insured people, place region, medical criminal record feelings
Condition is related, and each Claims Resolution mechanism can adjust between risk class and features described above according to the data accumulation and strategy of itself
Correlation, for example, the weight that the above-mentioned each feature of adjustment is shared in risk class judgement.In order to keep the description of the present application simple
Practice, this is repeated no more.
The pre-authorization required cost is expense involved in the current pre-authorization request of the insured people.
For example, if the risk class of insured people is "high" and pre-authorization required cost has been more than third quartile,
The insured people is determined as " doubtful not firm informing ".
For example, if the risk class of insured people be " in " and pre-authorization required cost be more than the seven or eight quantile,
The insured people is determined as " doubtful not firm informing ".
For example, pre-authorization required cost can not be considered further that if the risk class of insured people is " low ", it directly will be described
Insured people is determined as not " doubtful not firm informing ".
If step S500, the described insured people by system is determined as non-" doubtful not firm informing " and without other open question,
Then the pre-authorization system output result is " passing through ".
Wherein, other open questions include " doubtful medical history ", " doubtful chronic disease ", " doubtful remaining protection amount is not
Foot ", " doubtful to repeat case ", " doubtful exclusions ", " doubtful non-support area " etc..
If step S600, the described insured people is determined as " doubtful not firm informing " by system, the pre-authorization system is defeated
Result is " undetermined " out, is turned by (artificial) processing in backstage.
Wherein, the medical big data include the demographic characteristics of the retrievable each client of insurance institution, geographical feature,
Temporal characteristics (such as consultation time, medical interphase, insured time), medical characteristics are (as diagnosis, accurate visit, Medical Consumption are clear
List, medical institutions' scale, medical institutions' grade, medical institutions' the past criminal record label, doctor academic title etc.), fee properties (as every time
It is medical to spend), etc..
For example, above-mentioned data can be obtained from interior business data, public information channel, and/or third party's information channel.
The medical treatment big data may also include the secondary data by carrying out analytical calculation acquisition to statistical data, such as medical
The distribution at any time of the medical frequency (in 1 year) of person, medical expenditure, period always spend, expenditure pattern ratio, etc..
As an example, the preauthorization information includes the medical settlement data of client, as shown in Table 1 below:
Table 1
Optionally, after step sloo, the method may also include that
S110, if there is one or more of following situations, then it is " refusal " that system, which directly exports result:
Time-out application；
Relief；
In waiting period；
History information is not complete；
Without medical necessity；
Without remaining insured amount；
Non-effective declaration form；
It not yet sees and examines；
As an example, the decision rule of " doubtful non-support area " is as follows in step S500:
1) declaration form is that health insurance declaration form or policy judge according to insurance kind hospital subtype table in any subtype
Under, hospital of going to a doctor is associated with specific insurance kind；
2) declaration form is health insurance declaration form, and hospital category is " second level or the above public hospital of second level "；
As an example, the decision rule of " doubtful medical history " is as follows in step S500:
1) for single group, when " core under personal information protects especially agreement " meets fixed field (for example, in " especially agreement
Arrange in keyword ")；
2) single for health insurance, when " core under personal information protects especially agreement " field rule meets fixed field；
3) single for life insurance, when " declaration form is especially arranged " or " supplement is informed " field rule meets fixed field；
As an example, the decision rule of " doubtful exclusions " is as follows in step S500:
1) relief keyword is matched from " symptom or sign " or " disease name " or " cause of accident ", (for example, " exempting from
Arrange in duty field annex ")；
2) when being related to " artificial insemination ", " childbirth ", " pregnancy ", " miscarriage ", if corresponding insurance kind does not have female fertility duty
Appoint, etc. (for example, arrange in " relief field annex ")；
As an example, the decision rule of " doubtful chronic disease " is as follows in step S500:
1) when disease name is matched to chronic disease keyword, then prompt is chronic disease；
As an example, the decision rule of " doubtful remaining insured amount insufficient " is as follows in step S500:
If 1) provide the amount of money, pre-authorization project and the remaining protection amount of the thin item of the corresponding sole responsibility of pre-authorization type are judged
The amount of money with application is less than is that straight knot is prompted not pass through；
If 2) the thin item of sole responsibility cannot be matched, according to pre-authorization type with responsibility sport matching (such as corresponding be hospitalized of being hospitalized
Malpractice insurance), judge whether the summations of all remaining protection amounts under responsibility sport are less than the amount of money of application, is to prompt " directly to tie not
Pass through "；
As an example, the decision rule of " doubtful to repeat case " is as follows in step S500:
1) when pre-authorization type be hospitalized/dental clinic/female fertility, find and divide odd numbers, hospital, pre-authorization in system
There is the difference of [- 7 ,+15] in the admission date of all identical record of type, the admission date and search result record that judge typing,
Then case is repeated to be doubtful；
2) it when pre-authorization type is outpatient service, finds and divides odd numbers in system, hospital, all identical record of pre-authorization type,
There is the difference of [- 3 ,+7] on the medical date on the medical date and search result record that judge typing, then repeats case to be doubtful.
Optionally, step S400 includes: and calculates the accounting expense of pre-authorization to be in the section in statistical data, described in judgement
Whether expense is in the section that peels off,
Wherein, for risk class, normally insured people, the section definition that can will peel off are third quartile section, that is, system
Top 25% in counting, threshold value are third quartile.
Optionally, as shown in Fig. 2, in step S400, determine whether the medical expenditure of the client deviates from just as follows
Normal range:
Step S410, outlier Max is calculated,
As an example, Max=(IQR Upper-IQR Lower) * 2+IQR Upper, wherein IQR Upper indicates institute
State the third quartile in the expense section of the other statistical data of group, IQR Lower indicates the of described group of other expense section
One quartile；
Step S420, determine whether the medical expense of the client has been more than n*Max, wherein n is the coefficient between 1~3；
Wherein, the threshold value for being used for the insured people of high risk can be determined as n*Max, the threshold value for being used for the insured people of high risk is true
Being set to m*Max, wherein n, m are coefficient between 1~3, and n > m,
As method is simplified, above-mentioned threshold value can also be directly defined as to third quartile, the seven or eight quantile；
If the medical expense of step S430, the described client has been more than n*Max, determine that the medical expenditure of the client is inclined
From normal range (NR).
3, pre-authorization is from core system
According to an embodiment of the invention, additionally providing a kind of pre-authorization from core system, for executing the embodiment of the present invention
Each step of the method.
Fig. 3 is the functional block diagram according to the pre-authorization of the embodiment of the present invention from core system.As shown in figure 3, institute
Pre-authorization is stated to specifically include that from core system
Pre-authorization application receiving module, for receiving the pre-authorization Shen for the pre-authorization project that related declaration form is arranged from insured people
Please；Wherein, the pre-authorization application mainly includes insured people's information, insured people's state of an illness, medical services title, treatment project, doctor
Treat drug and consumptive material title, the expense of corresponding each treatment project, etc.；
Pre-authorization expense computing module, for calculating settling fee relevant to the pre-authorization application；
Insured people's feature obtains module, for according to the above- mentioned information in the pre-authorization application, further from medical big
The characteristic information of insured people is obtained in data,
Wherein, the characteristic information is the feature of each dimension of insured people, comprising:
Can directly from available data derived feature, as demographic characteristics, geographical feature, temporal characteristics (as it is medical when
Between, medical interphase, insured time etc.), medical characteristics (such as diagnosis, accurate visit, Medical Consumption inventory, medical institutions' scale, cure
Treat mechanism grade, medical institutions' the past criminal record label, doctor academic title etc.), fee properties (being spent as medical every time), etc.；
Medical frequency (in 1 year), point of medical expenditure at any time by calculating the secondary data obtained, such as clients
Cloth, period always spend, expenditure pattern ratio, etc.,
Risk of fraud determination module determines the risk class of insured people for the characteristic information according to the insured people, and
In conjunction with the pre-authorization required cost, judge whether insured people is doubtful " not firm informing "；
Wherein, a possibility that described " not firm informing ", is related to the risk class of insured people and pre-authorization required cost, ginseng
The risk class of guarantor is higher, pre-authorization required cost is higher (irrelevance with critical field), then " the not firm informing "
Possibility is higher；
Pre-authorization from core processing module, if for the insured people by system be determined as non-" doubtful not firm informing " and
Without other open questions, then the pre-authorization system output result is " passing through ", if the insured people is judged to " doubting by system
Like not firm informing ", then the pre-authorization system output result is " undetermined ", is turned by (artificial) processing in backstage.
In addition, different embodiments of the invention by software module or can also be stored in one or more computer-readable
The mode of computer-readable instruction on medium is realized, wherein the computer-readable instruction is when by processor or equipment group
When part executes, different embodiment of the present invention is executed.Similarly, software module, computer-readable medium and Hardware Subdivision
Any combination of part is all expected from the present invention.The software module can be stored in any type of computer-readable storage
On medium, such as RAM, EPROM, EEPROM, flash memory, register, hard disk, CD-ROM, DVD etc..
4, the system for being mounted with application program of embodiment according to the present invention
Referring to Fig. 4, it illustrates the running environment of the system according to an embodiment of the present invention for being mounted with application program.
In the present embodiment, the system of the installation application program is installed and is run in electronic device.The electronics
Device can be desktop PC, notebook, palm PC and server etc. and calculate equipment.The electronic device may include but not
It is limited to memory, processor and display.This Figure only shows the electronic devices with said modules, it should be understood that
It is not required for implementing all components shown, the implementation that can be substituted is more or less component.
The memory can be the internal storage unit of the electronic device, such as electronics dress in some embodiments
The hard disk or memory set.The memory is also possible to the External memory equipment of the electronic device in further embodiments,
Such as the plug-in type hard disk being equipped on the electronic device, intelligent memory card (Smart Media Card, SMC), secure digital
(Secure Digital, SD) card, flash card (Flash Card) etc..Further, the memory can also both include institute
The internal storage unit for stating electronic device also includes External memory equipment.The memory is installed on the electronics dress for storing
The application software and Various types of data set, such as the program code etc. of the system for installing application program.The memory may be used also
For temporarily storing the data that has exported or will export.
The processor can be in some embodiments central processing unit (Central Processing Unit,
CPU), microprocessor or other data processing chips, for running the program code stored in the memory or processing data,
Such as execute the system etc. of the installation application program.
The display can be in some embodiments light-emitting diode display, liquid crystal display, touch-control liquid crystal display with
And OLED (Organic Light-Emitting Diode, Organic Light Emitting Diode) touches device etc..The display is for showing
Show the information handled in the electronic device and for showing visual customer interface, such as application menu interface, answers
With icon interface etc..The component of the electronic device is in communication with each other by system bus.
Through the above description of the embodiments, those skilled in the art is it will be clearly understood that above embodiment
In method can realize by means of software and necessary general hardware platform, naturally it is also possible to realized by hardware,
But the former is more preferably embodiment in many cases.Based on this understanding, the technical solution of the application of the present invention is substantially
The part that contributes to existing technology can be embodied in the form of Software Commodities in other words, which deposits
Storage in a storage medium (such as ROM/RAM, magnetic disk, CD), including some instructions are used so that terminal device (can be with
It is mobile phone, computer, server, air conditioner or the network equipment etc.) execute side described in each embodiment of the application of the present invention
Method.
That is, according to an embodiment of the invention, additionally provide a kind of computer readable storage medium, the computer
The program of the method for executing embodiment according to the present invention is stored on readable storage medium storing program for executing, described program is processed
When device executes, each step of the method is executed.
By upper, it will be appreciated that for illustrative purposes, specific embodiments of the present invention are described herein, still, can make
Each modification, without departing from the scope of the present invention.It will be apparent to one skilled in the art that drawn in flow chart step or this
In the operation that describes and routine can be varied in many ways.More specifically, the order of step can be rearranged, step can be executed parallel
Suddenly, step can be omitted, it may include other steps can make the various combinations or omission of routine.Thus, the present invention is only by appended power
Benefit requires limitation.
Claims (10)
1. it is a kind of based on the pre-authorization of data processing from kernel method, be applied to Medical Insurance Organizations, which is characterized in that the side
Method the following steps are included:
Step 1 receives insured people for the pre-authorization application of Claims Resolution, and the pre-authorization application includes the personal letter of the insured people
Breath and the medical information of the insured people；
Step 2, according to the medical information of the insured people, calculate settling fee relevant to the pre-authorization application；
Step 3, according to the personal information of the insured people and the medical information of the insured people, further from medical big number
According to the middle characteristic information for obtaining insured people；
Step 4, according to the characteristic information of the acquired insured people, determine the risk class of the insured people；
Step 5, the risk class according to the insured people and settling fee relevant to the pre-authorization application, judge institute
State in pre-authorization application whether doubtful there are not firm information；
If the result judged in step 6, step 5 is "Yes", turn by background process.
2. it is according to claim 1 based on the pre-authorization of data processing from kernel method, which is characterized in that the insured people's
Medical information includes insured people's state of an illness, medical services title, treatment project, Medicines and consumptive material title, corresponding each treatment
The expense of project.
3. it is according to claim 1 based on the pre-authorization of data processing from kernel method, which is characterized in that wherein, the spy
Reference breath include: the demographic characteristics of the insured people, geographical feature, medical act temporal characteristics, medical act geographical feature,
Medical act fee properties.
4. according to claim 1 to described in any of 3 based on the pre-authorization of data processing from kernel method, which is characterized in that
In step 4, according to the characteristic information of the insured people, by the risk class of the insured people be divided into "high", " in ", " low "
Three-level,
Wherein, the characteristic information includes:
The demographic characteristics of the insured people, geographical feature, medical characteristics, fee properties；
The distribution at any time of the medical frequency of the insured people, medical expenditure, period always spend, expenditure pattern ratio.
5. it is according to claim 4 based on the pre-authorization of data processing from kernel method, which is characterized in that in steps of 5:
If the risk class of insured people is "high" and the settling fee be more than with risk class is "high" corresponding
One threshold value then judges that doubtful in the pre-authorization application there are not firm information；
If the risk class of insured people be " in " and the settling fee be more than be with risk class " in " corresponding the
Two threshold values then judge that doubtful in the pre-authorization application there are not firm information.
6. it is according to claim 1 based on the pre-authorization of data processing from kernel method, it is characterised in that further include:
If the judging result in step 7, step 5 is "No", inquires and whether need to check other projects, including following items
One or more of: " doubtful medical history ", " doubtful chronic disease ", " doubtful remaining insured amount insufficient ", " doubtful to repeat case ",
" doubtful exclusions ", " doubtful non-support area "；
Step 8, if you do not need to check other projects or other projects it is being checked after it is normal, then by pre-granted
The result of Quan Zihe is determined as " passing through ".
7. it is according to claim 5 based on the pre-authorization of data processing from kernel method, which is characterized in that the first threshold
For third quartile, the second threshold is the seven or eight quantile.
8. it is according to claim 5 based on the pre-authorization of data processing from kernel method, which is characterized in that it is following determine described in
First threshold and the second threshold:
Step S410, outlier Max=(IQR Upper-IQR Lower) * 2+IQR Upper is calculated, wherein IQR Upper
Indicate the third quartile in the expense section of the statistical data of risk class, IQR Lower indicates the expense of the risk class
With the first quartile in section；
Step S420, the first threshold is determined as n*Max, the second threshold is determined as m*Max, and wherein n, m are 1~3
Between coefficient, and n > m.
9. a kind of pre-authorization for method described in any of perform claim requirement 1 to 8 is from core system, feature exists
In, comprising:
Pre-authorization application receiving module, for receiving insured people for the pre-authorization application of Claims Resolution, the pre-authorization application includes
The medical information of the personal information of the insured people and the insured people；
Pre-authorization expense computing module, for calculating settling fee relevant to the pre-authorization application；
Insured people's feature obtains module, for according to the personal information of the insured people and the medical information of the insured people,
The characteristic information of insured people is further obtained from medical big data；
Risk of fraud determination module determines the risk class of the insured people for the characteristic information according to the insured people, and
According to the risk class of the insured people and settling fee relevant to the pre-authorization application, the pre-authorization Shen is judged
Please in whether doubtful there are not firm information；
Pre-authorization, if the judging result for the risk of fraud determination module is "Yes", turns by rear from core processing module
Platform processing.
10. a kind of computer readable storage medium, which is characterized in that be stored with computer on the computer readable storage medium
Program, when the computer program is executed by processor, perform claim require any of 1 to 8 described in method the step of.
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