CN109670788A - Medical insurance checking method, device, equipment and storage medium based on data analysis - Google Patents
Medical insurance checking method, device, equipment and storage medium based on data analysis Download PDFInfo
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- 238000000034 method Methods 0.000 title claims abstract description 55
- 238000007405 data analysis Methods 0.000 title claims abstract description 40
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- 239000003814 drug Substances 0.000 claims abstract description 297
- 229940079593 drug Drugs 0.000 claims abstract description 133
- 238000012550 audit Methods 0.000 claims abstract description 85
- 239000000463 material Substances 0.000 claims abstract description 80
- 201000010099 disease Diseases 0.000 claims description 46
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- 238000004590 computer program Methods 0.000 claims description 12
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- 238000012015 optical character recognition Methods 0.000 description 4
- 238000012805 post-processing Methods 0.000 description 4
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- 238000012795 verification Methods 0.000 description 3
- 238000005516 engineering process Methods 0.000 description 2
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- 238000002483 medication Methods 0.000 description 2
- 238000007781 pre-processing Methods 0.000 description 2
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Abstract
The invention discloses a kind of medical insurance checking methods based on data analysis, comprising the following steps: the audit request for receiving medical insurance claims obtains pending Claims Resolution material;It parses the Claims Resolution material and obtains Claims Resolution relevant information, whether judged in the medical insurance claims according to the Claims Resolution relevant information comprising special pharmacology compensation;If paying in the medical insurance claims comprising special pharmacology, judge whether the special medicine meets medication rule;If spy's medicine meets medication rule, exports medical insurance claims audit and pass through.The invention also discloses a kind of medical insurances based on data analysis to audit device, equipment and storage medium.The present invention obtains Claims Resolution relevant information using the OCR technique identification Claims Resolution material, then analyzes Claims Resolution relevant information, progress medical insurance claims audit, and the application careful audit in medical insurance is audited is regular to medication, realizes comprehensive, accurately medical insurance audit.
Description
Technical field
The present invention relates to medical insurance management domains, more particularly to based on data analysis medical insurance checking method, device, equipment and
Storage medium.
Background technique
Traditional medical insurance audit is to rely on manual examination and verification mostly, since human resources are limited and medical insurance audit document quantity is huge
Greatly, cause medical insurance Review Cycle too long, therefore, medical insurance audit platform occur.
Current medical insurance audit platform feature is too simple, can not cope with that occur in practical review process all kinds of are special to ask
Topic.That is, the true and false of the current audit platform generally directed to medical insurance material, reimbursement range etc. are audited;Such medical insurance audit
Not comprehensively, it is easy to appear the problem of medical insurance document audit mistake, how comprehensively, accurately medical insurance, which is audited, becomes currently urgently
The technical issues of solution.
Summary of the invention
The main purpose of the present invention is to provide the medical insurance checking method analyzed based on data, device, equipment and storages to be situated between
Matter, it is intended to realize that comprehensively, accurately medical insurance claims are audited.
To achieve the above object, the present invention provides the medical insurance checking method analyzed based on data, described to be analyzed based on data
Medical insurance checking method the following steps are included:
The audit request for receiving medical insurance claims, obtains pending Claims Resolution material;
It parses the Claims Resolution material and obtains Claims Resolution relevant information, the medical insurance claims are judged according to the Claims Resolution relevant information
In whether paid for comprising special pharmacology;
If paying in the medical insurance claims comprising special pharmacology, judge whether the special medicine meets medication rule;
If spy's medicine meets medication rule, exports medical insurance claims audit and pass through.
Optionally, the parsing Claims Resolution material obtains Claims Resolution relevant information, is judged according to the Claims Resolution relevant information
It whether include the step of special pharmacology is paid in the medical insurance claims, comprising:
The Claims Resolution material is pre-processed, and extracts the characteristic information in the Claims Resolution material after pretreatment;
The characteristic information is input to preset characters classifier, obtains character information, and the character information is carried out
Post-processing obtains Claims Resolution relevant information;
The medicine mark in the Claims Resolution relevant information is extracted, default special medicine logo collection is inquired, judges the default spy
It whether there is and the matched target identification of the medicine mark in medicine logo collection;
If exist in the default special medicine logo collection with the matched target identification of the medicine mark, determine the doctor
Factoring is paid in paying for comprising special pharmacology.
Optionally, described that the characteristic information is input to preset characters classifier, obtain character information, and by the word
After the step of symbol information is post-processed, and Claims Resolution relevant information is obtained, comprising:
The User Identity in the Claims Resolution relevant information is obtained, default medical data base is inquired, obtains the user
The corresponding disease treatment information of identity;
The disease treatment information is compared with the disease information in the Claims Resolution relevant information, to judge the reason
Whether true pay for relevant information;
If the Claims Resolution relevant information is untrue, the medical insurance claims are rejected;
If the Claims Resolution relevant information is true, the medicine mark extracted in the Claims Resolution relevant information is executed, inquiry is pre-
If special medicine logo collection, judge to whether there is and the matched target identification of the medicine mark in the default special medicine logo collection
The step of.
Optionally, if paying in the medical insurance claims comprising special pharmacology, judge whether the special medicine meets medication rule
Then the step of, comprising:
If paying in the medical insurance claims comprising special pharmacology, the medical history record and prescription in the Claims Resolution relevant information are obtained
Information;
According to the medical history record and the prescription information, the practical medication information of the special medicine is obtained;
It inquires default drug and uses rule list, the Standard dose information of the special medicine is obtained, by the practical medication information
It is compared with the Standard dose information;
If the practical medication information and the Standard dose information matches, spy's medicine meets medication rule.
Optionally, described according to the medical history record and the prescription information, obtain the practical medication information of the special medicine
The step of, comprising:
The disease information in the medical history record is obtained, the drug for obtaining spy's medicine described in the prescription information, which uses, to be said
It is bright;
The disease information is compared with the drug operation instruction, judges whether the special medicine suits the medicine to the illness;
If spy's medicine is suited the medicine to the illness, the disease information and the drug operation instruction are analyzed, obtains the use of the special medicine
Medicine time and dosage, using the administration time and the dosage as practical medication information.
Optionally, the step of audit for receiving medical insurance claims requests, obtains pending Claims Resolution material, comprising:
The audit request for receiving medical insurance claims, exports upload material prompt information, to prompt user to upload medical insurance claims pair
The electronic document answered;
The electronic document that the user uploads is received, judges whether the electronic document meets default screening rule;
If the electronic document does not meet the default screening rule, prompt information is exported, to prompt user's weight
It is new to upload;
If the electronic document meets the default screening rule, using the electronic document as pending Claims Resolution material
Material.
Optionally, the parsing Claims Resolution material obtains Claims Resolution relevant information, is judged according to the Claims Resolution relevant information
After the step of whether including special pharmacology compensation in the medical insurance claims, comprising:
If not including special pharmacology in medical insurance claims to pay for, the medical insurance identification information of Claims Resolution relevant information is obtained;
Default medical insurance platform is inquired, the corresponding medical insurance declaration form of the medical insurance identification information and the medical insurance declaration form are obtained
In medical insurance type;
The medical insurance type is compared with the Claims Resolution type in the Claims Resolution relevant information;
If the Claims Resolution type matching in the medical insurance type and the Claims Resolution relevant information, it is logical to export medical insurance claims audit
It crosses.
In addition, to achieve the above object, the present invention also provides a kind of medical insurances based on data analysis to audit device, the base
Include: in the medical insurance audit device of data analysis
Auditing module is received, the audit for receiving medical insurance claims is requested, and pending Claims Resolution material is obtained;
Analysis judgment module obtains Claims Resolution relevant information for parsing the Claims Resolution material, according to the related letter of the Claims Resolution
Breath judges whether pay for comprising special pharmacology in the medical insurance claims;
Drug judgment module, if judging whether the special medicine meets for paying in the medical insurance claims comprising special pharmacology
Medication rule;
Output module is audited, if meeting medication rule for the special medicine, medical insurance claims audit is exported and passes through.
In addition, to achieve the above object, the present invention also provides a kind of medical insurances based on data analysis to audit equipment;
The medical insurance audit equipment based on data analysis includes: memory, processor and is stored on the memory
And the computer program that can be run on the processor, in which:
Medical insurance audit as described above based on data analysis is realized when the computer program is executed by the processor
The step of method.
In addition, to achieve the above object, the present invention also provides computer storage mediums;
Computer program, the realization when computer program is executed by processor are stored in the computer storage medium
Such as the step of the above-mentioned medical insurance checking method based on data analysis.
A kind of medical insurance checking method, device, equipment and storage medium based on data analysis that the embodiment of the present invention proposes,
Terminal receives the audit request of medical insurance claims, obtains pending Claims Resolution material;It parses the Claims Resolution material and obtains Claims Resolution correlation
Whether information judges in the medical insurance claims according to the Claims Resolution relevant information comprising special pharmacology compensation;If in the medical insurance claims
It is paid for comprising special pharmacology, then judges whether the special medicine meets medication rule;If spy's medicine meets medication rule, medical insurance is exported
Claims Review passes through, and is parsed when carrying out medical insurance claims for Claims Resolution material in the present invention, obtains Claims Resolution relevant information, eventually
End is according to Claims Resolution relevant information, that is, terminal obtains the Claims Resolution type in Claims Resolution relevant information, and (kinds of Diseases, are hospitalized at medication information
Information etc.), the information such as Claims Resolution amount judge whether pay for comprising special pharmacology in medical insurance claims, if wrapping in the medical insurance claims
It is paid for containing special pharmacology, then judges whether spy's medicine meets medication rule, careful audit in medical insurance audit is directed in the application and arrives spy
Medicine meets medication rule, realizes and realizes that comprehensively, accurately medical insurance claims are audited for medical insurance medication.
Detailed description of the invention
Fig. 1 is the apparatus structure schematic diagram for the hardware running environment that the embodiment of the present invention is related to;
Fig. 2 is the flow diagram for the medical insurance checking method first embodiment analyzed the present invention is based on data;
Fig. 3 is that the functional block diagram of one embodiment of device is audited in the medical insurance analyzed the present invention is based on data.
The embodiments will be further described with reference to the accompanying drawings for the realization, the function and the advantages of the object of the present invention.
Specific embodiment
It should be appreciated that the specific embodiments described herein are merely illustrative of the present invention, it is not intended to limit the present invention.
Since existing medical insurance audit is to rely on manual examination and verification mostly, document is audited in face of the medical insurance that pile up like a mountain, it is traditional
Manual examination and verification mode can not cope with medical insurance data volume so huge at present.Therefore, there are some medical insurance audit platforms, this
It is generally only to be audited for the true and false of material, or audited to the type of Claims Resolution in a little audit platforms, is managed determining
Compensation material is true, and Claims Resolution type just exports the conclusion that medical insurance claims pass through without departing from Claims Resolution range, and cannot more comprehensively
Carry out verify, for example, user's first goes to A hospital to see a doctor using medical insurance, opened drug 1 comprising Rational Dosage in doctor's prescription,
User Jia Zaiqu B hospital sees a doctor, and has opened drug 1 comprising Rational Dosage in doctor's prescription, and user's first oneself is then used one
In addition extra drug 1 resell and earns intermediate price difference by Some Drugs 1 again, such situation, current medical insurance audit is not
It can effectively be audited.
The present invention provides a solution, makes to obtain Claims Resolution relevant information, terminal by parsing medical insurance material
Whether judged in the medical insurance claims according to Claims Resolution relevant information comprising special pharmacology compensation;If including special pharmacology in the medical insurance claims
It pays for, then judges whether the special medicine meets medication rule;If spy's medicine meets medication rule, it is logical to export medical insurance claims audit
It crosses.The present invention is based on the analysis of data, realize that comprehensive, accurately medical insurance is audited.
As shown in Figure 1, the terminal that Fig. 1 is the hardware running environment that the embodiment of the present invention is related to (is called based on data
Equipment is audited in the medical insurance of analysis, wherein the medical insurance audit equipment based on data analysis can be to be analyzed by being individually based on data
Medical insurance audit device constitute, be also possible to audit device with medical insurance analyze based on data by other devices to combine formed) tie
Structure schematic diagram.
The terminal of that embodiment of the invention can be also possible to mobile terminal with fixed terminal, e.g., the Intelligent air with network savvy
Tune, intelligent electric lamp, intelligent power, intelligent sound box, autonomous driving vehicle, PC (personal computer) personal computer, intelligence
Energy mobile phone, tablet computer, E-book reader, portable computer etc..
As shown in Figure 1, the terminal may include: processor 1001, for example, central processing unit Central Processing
Unit, CPU), network interface 1004, user interface 1003, memory 1005, communication bus 1002.Wherein, communication bus 1002
For realizing the connection communication between these components.User interface 1003 may include display screen (Display), input unit ratio
Such as keyboard (Keyboard), optional user interface 1003 can also include standard wireline interface and wireless interface.Network interface
1004 may include optionally that (such as Wireless Fidelity WIreless-FIdelity, WIFI connect standard wireline interface and wireless interface
Mouthful).Memory 1005 can be high speed RAM memory, be also possible to stable memory (non-volatile memory),
For example, magnetic disk storage.Memory 1005 optionally can also be the storage device independently of aforementioned processor 1001.
Optionally, terminal can also include camera, RF (Radio Frequency, radio frequency) circuit, sensor, audio
Circuit, WiFi module;Input unit, than display screen, touch screen;Network interface can in blanking wireless interface in addition to WiFi, bluetooth,
Probe etc..Wherein, sensor such as optical sensor, motion sensor and other sensors.Specifically, optical sensor can wrap
Include ambient light sensor and proximity sensor;Certainly, mobile terminal can also configure gyroscope, barometer, hygrometer, thermometer,
The other sensors such as infrared sensor, details are not described herein.
It will be understood by those skilled in the art that the restriction of the not structure paired terminal of terminal structure shown in Fig. 1, can wrap
It includes than illustrating more or fewer components, perhaps combines certain components or different component layouts.
As shown in Figure 1, the computer software product, which is stored in a storage medium, (storage medium: is called computer storage
Medium, computer media, readable medium, readable storage medium storing program for executing, computer readable storage medium are directly medium etc., such as
RAM, magnetic disk, CD) in, including some instructions are used so that a terminal device (can be mobile phone, computer, server, sky
Adjust device or the network equipment etc.) method described in each embodiment of the present invention is executed, as a kind of depositing for computer storage medium
It may include operating system, network communication module, Subscriber Interface Module SIM and computer program in reservoir 1005.
In terminal shown in Fig. 1, network interface 1004 is mainly used for connecting background server, carries out with background server
Data communication;User interface 1003 is mainly used for connecting client (user terminal), carries out data communication with client;And processor
1001 can be used for calling the computer program stored in memory 1005, and execute that following embodiment of the present invention provides based on
Step in the medical insurance checking method of data analysis.
The present invention is based on data analysis medical insurance checking method first embodiment in, it is described based on data analysis medical insurance
Checking method includes:
The audit request for receiving medical insurance claims, obtains pending Claims Resolution material;
It parses the Claims Resolution material and obtains Claims Resolution relevant information, the medical insurance claims are judged according to the Claims Resolution relevant information
In whether paid for comprising special pharmacology;
If paying in the medical insurance claims comprising special pharmacology, judge whether the special medicine meets medication rule;
If spy's medicine meets medication rule, exports medical insurance claims audit and pass through.
After user buys social medical insurance or commercial medical insurance in the application, there is corresponding medical treatment in user
When Claims Resolution event, user triggers the audit request of medical insurance claims, and terminal receives the audit request of medical insurance claims, and corresponding display material
Expect input page, so that user inputs Claims Resolution material, terminal obtains the Claims Resolution material of user's input, and carries out to Claims Resolution material
Audit, judges whether the medical insurance claims of user's application meet Claims Resolution standard, specifically:
It is described based on data point the present invention is based in the first embodiment of the medical insurance checking method of data analysis referring to Fig. 2
The medical insurance checking method of analysis includes:
Step S10 receives the audit request of medical insurance claims, obtains pending Claims Resolution material.
Terminal receives the audit request of medical insurance claims, wherein and the triggering mode of the audit request of medical insurance claims is varied,
It is not construed as limiting in the present embodiment, for example, user triggers the audit of medical insurance claims on the interface for the application software that terminal one is specified
Request or the audit request of user's verbal order triggering medical insurance claims, when terminal receives the audit request of medical insurance claims,
Terminal shows the prompt information of medical insurance claims upload material, and user uploads medical insurance danger according to prompt information on medical insurance claims interface
Relevant Claims Resolution material, terminal obtain the Claims Resolution material of user's upload as pending Claims Resolution material.
It wherein, include: 1, insurance contract original part in the Claims Resolution material;2, the identity document original part of insurant;3, it fills out
Write Claims Resolution application materials, comprising: Claims Resolution application, letter of authority (if any act on behalf), authorized bank are transferred accounts application;4, it is protected
The medical expense receipt original part and the corresponding inventory of receipt that dangerous people occurs in hospital outpatient or during being hospitalized;5, fixed hospital is examined
Treat record (such as patient medical history original part and be hospitalized after inpatient cases copy, discharge abstract, diagnosis prove, various inspections
Report etc.);6, because of accident or disease death and deformity, also need to provide contingency prove, death certificate and specified residual
Disease appraisal organization assay certificate etc..
Further, screening rule is preset in the present embodiment terminal, wherein preset screening rule can be according to concrete scene
Setting, for example, including clarity rule, the electronics material that terminal uploads user by presetting screening rule in default screening rule
Material is screened for the first time, and will meet the electronic material of default screening rule as pending Claims Resolution material, to settle a claim
The audit of material, specifically:
Step a receives the audit request of medical insurance claims, exports upload material prompt information, to prompt user to upload medical insurance
It settles a claim corresponding electronic document;
Step b receives the electronic document that the user uploads, and judges whether the electronic document meets default screening rule
Then;
Step c exports prompt information if the electronic document does not meet the default screening rule, described in prompt
User uploads again;
Step d, if the electronic document meets the default screening rule, using the electronic document as pending
Claims Resolution material.
That is, terminal receives the audit request of medical insurance claims, terminal exports upload material prompt information, to prompt user to upload
The corresponding electronic document of medical insurance claims;User uploads relevant electronic document, and terminal receives the electronic document that the user uploads,
Terminal is screened according to the electronic document that preset screening rule uploads user, that is, terminal believes the attribute of electronic document
Breath and default screening rule are compared, and obtain comparison result, terminal judges whether the electronic document accords with according to comparison result
Close default screening rule;If the electronic document does not meet the default screening rule, for example, the electronic document lattice that user uploads
Formula does not meet default screening rule, then terminal exports prompt information, to prompt the user to upload again;If the then electronics text
Shelves meet the default screening rule, then using the electronic document as pending Claims Resolution material.
After terminal receives the audit request for receiving medical insurance claims in the present embodiment, terminal shows medical insurance on interface
Claims Resolution interface, user can be based on electronic document be uploaded on medical insurance claims interface, terminal is provided with default screening rule to user
The electronic document of upload carries out preliminary audit survey, and the principle of program saving is realized in the present embodiment, is efficiently avoided due to upper
Pass the problem of electronic file form is against regulation, and caused Review Cycle increases.
Step S20 parses the Claims Resolution material and obtains Claims Resolution relevant information, according to Claims Resolution relevant information judgement
Whether paid for comprising special pharmacology in medical insurance claims.
Terminal parses the Claims Resolution material and obtains Claims Resolution relevant information, wherein Claims Resolution relevant information includes: user identity mark
Know information (for example, user identity card number), user's disease information (for example, the disease on Medical record records), user's medical insurance letter
It ceases (for example, medical insurance type of user, medical insurance policy information), user's medication information (for example, user's prescription information) etc., this reality
Apply given in example parse it is described Claims Resolution material obtain Claims Resolution relevant information specific implementation:
That is, being identified in the present embodiment using OCR (Optical Character Recognition, optical character identification)
Technology handles each Claims Resolution material;OCR refers to that electronic equipment (such as scanner or digital camera) checks and prints on paper
Character, determine its shape by detecting dark, bright mode, shape then translated into computword with character identifying method
Process;Specifically: 1. first detect and extract character area (Text region);2. followed by radon hough transformation etc.
Method carries out text correction;3. being partitioned into the picture of the text of uniline by projection histogram;4. being finally directed to the picture of text
Character recognition is carried out, for example, searching for as segmentation candidates point and based on projection histogram extreme point using preset characters classifier
Optimal partition point.After searching cut-point, character recognition preset characters classifier is used for single character.That is, adjustment
(preset characters classifier has decision tree, nerve to extraction characteristic information-preset characters classifier to gray scale-binaryzation-correcting image-
Network etc.).
Claims Resolution material is handled using OCR identification technology in the present embodiment, does not need manually to check, so that it may automatic
Obtained Claims Resolution relevant information.
Further, after obtaining Claims Resolution relevant information, terminal judges whether to wrap according to obtained Claims Resolution relevant information
It is paid for containing special pharmacology;Wherein, special medicine refers to the medication for treating certain special diseases, and the price of special medicine is higher under normal conditions;This reality
Apply the specific implementation for giving in example and judging whether to pay for comprising special pharmacology in the medical insurance claims according to the Claims Resolution relevant information
Mode:
That is, terminal obtains the information concerning medications in Claims Resolution relevant information, terminal obtains the drug in information concerning medications
Medicine mark information is compared with the identification information of each special medicine in default special medicine logo collection for identification information, terminal,
Wherein, it presets special medicine logo collection and refers to pre-set special medicine identification information set;If existing in default spy's medicine logo collection
It identifies, then whether is paid for comprising special pharmacology in medical insurance claims with the special medicine of medicine mark information matches, it is on the contrary.
Step S30 judges whether the special medicine meets medication rule if paying in the medical insurance claims comprising special pharmacology.
If paying in medical insurance claims described in terminal comprising special pharmacology, terminal needs audit to the medication of special medicine,
Judge whether the special medicine meets medication rule, to prevent special pharmacology from apologizing mistake.
Specifically, it is provided in the present embodiment and judges whether the special medicine meets medication rule, it can be according to the drug of special medicine
Judged using rule, mainly around several aspects: whether 1. special medicines suit the medicine to the illness;2, whether the dosage of special medicine complies with standard;
3. whether the administration time of special medicine complies with standard, if above-mentioned all meet, terminal may determine that the special medicine meets medication rule.
Medication rule in the present embodiment for special medicine is audited, it is contemplated that the use standard information of special medicine, so that the medication of special medicine
The case where audit is more comprehensively careful, avoids the reimbursement of special medicine excess.
Step S40 exports medical insurance claims audit and passes through if spy's medicine meets medication rule.
If terminal determines that the special medicine meets medication rule, that is, terminal determines that medical insurance claims meet rule, terminal output doctor
Claims Review is protected to pass through.Further, after terminal determines that medical insurance audit passes through, terminal can carry out the granting of medical insurance, improve
The review efficiency of medical insurance;If terminal determines that the special medicine does not meet medication rule, terminal determines that medical insurance claims are not inconsistent normally,
Terminal output medical insurance claims audit does not pass through.
It is parsed when carrying out medical insurance claims for Claims Resolution material in the present embodiment, obtains Claims Resolution relevant information, terminal
According to Claims Resolution relevant information, that is, terminal obtains the Claims Resolution type in Claims Resolution relevant information, and (kinds of Diseases, medication information are hospitalized and are believed
Breath etc.), the information such as Claims Resolution amount judge whether pay for comprising special pharmacology in medical insurance claims, if including in the medical insurance claims
Special pharmacology is paid for, then judges whether spy's medicine meets medication rule, and careful audit in medical insurance audit is directed in the application and arrives special medicine
Meet medication rule, realizes and realize that comprehensively, accurately medical insurance claims are audited for medical insurance medication.
Further, it on the basis of first embodiment of the invention, proposes the medical insurance analyzed the present invention is based on data and examines
The second embodiment of kernel method.
It is the refinement of step S20 in first embodiment in the present embodiment, the parsing Claims Resolution material is given in the present embodiment
Whether material obtains Claims Resolution relevant information, according to the Claims Resolution relevant information, judge in the medical insurance claims comprising special pharmacology compensation
Specific implementation, the medical insurance checking method based on data analysis include:
Step S21 pre-processes the Claims Resolution material, and extracts the feature in the Claims Resolution material after pretreatment
Information.
It is pre-processed in the present embodiment for Claims Resolution material, wherein Claims Resolution material is that user uploads in first embodiment
Claims Resolution material, do not repeat in the present embodiment;Terminal carries out pretreatment processing to the Claims Resolution material comprising text so as to subsequent
Carry out feature information extraction, text information identification.
Carrying out pretreated main purpose to the Claims Resolution material in the present embodiment is the garbage reduced in image, with
Just facilitate subsequent processing.Claims Resolution pretreatment include usually have: gray processing (if it is color image), noise reduction, binaryzation,
Character cutting and normalize these sub-steps.Specifically, after binaryzation, image is only left two kinds of colors, i.e., black and white,
One of them is image background, another color seeks to the text of identification.During pretreated, noise reduction is also related to
(influence of the quality of noise reduction to feature information extraction is very big), noise reduction is obtained information and carries out character cutting by terminal, that is, by image
In Text segmentation at single Text region when be the one word identification of a word.In addition, pretreatment further includes normalization
Processing, normalized be single character image is regular to same size, under the same specification, using unified calculation
Method.
After pretreatment of settling a claim, characteristic information of the terminal extraction after pre-processing in the Claims Resolution material, feature
Information is the key message for identifying text, and each different text can be transferred through characteristic information and other texts and carry out area
Point.After characteristic information has been determined, terminal possibly carries out Feature Dimension Reduction, if the too high (feature one of the dimension of characteristic information
As indicated with a vector, the dimension i.e. number of components of the vector), the efficiency identified will receive very big influence, this implementation
Pre-process to Claims Resolution material in example is to improve recognition rate and accuracy rate.
The characteristic information is input to preset characters classifier by step S22, obtains character information, and by the character
Information is post-processed, and Claims Resolution relevant information is obtained.
Terminal by the characteristic information of extraction be input to preset characters classifier (set character preset characters classifier refer to it is default
Be arranged for carrying out the preset characters classifier of character information identification, it should be added that, the present embodiment the step of
Before, it is also necessary to preset characters classifier is trained, for example, using svm, neural network etc does not go to live in the household of one's in-laws on getting married in the present embodiment
It states);Preset characters classifier just classifies to characteristic information, and determining this characteristic information, which text this is identified as, and obtains
Corresponding character information.
Further, terminal also needs to post-process obtained character information, and post-processing is for character information
It optimizes, firstly, the classification of preset characters classifier is sometimes not necessarily right-on, such as the knowledge to Chinese character
Not, due to the presence of nearly word form in Chinese character, it is easy to which a word is identified as its nearly word form.It can go to solve this in post-processing
Problem is corrected by language model, for example, set character preset characters classifier will " where " be identified as " which being deposited
In ", by post-process language model can find " where deposit " be it is wrong, be then corrected.Furthermore it can be tasted in post-processing
Examination goes to be formatted recognition result.Claims Resolution material is handled in the present embodiment, the Claims Resolution correlation letter that ensure that
The accuracy of breath.
Step S23 extracts the medicine mark in the Claims Resolution relevant information, inquires default special medicine logo collection, judges institute
Stating whether there is and the matched target identification of the medicine mark in default special medicine logo collection.
After obtaining Claims Resolution relevant information, terminal extracts the medicine mark in the Claims Resolution relevant information, wherein drug
Mark refers to the identification information of drug variety for identification, for example, the title of drug or unitized medicine number, terminal base
Inquiring default special medicine logo collection in medicine mark, (default spy's medicine logo collection refers to pre-set special medicine identification information collection
Close), judge to whether there is and the matched target identification of the medicine mark in the default special medicine logo collection, that is, terminal will
Obtained medicine mark is compared with the mark of each special medicine preset in default special medicine logo collection, obtains comparison result,
Terminal judges to pay in the medical insurance claims comprising special pharmacology according to comparison result.
Step S24, if exist in the default special medicine logo collection with the matched target identification of the medicine mark, sentence
It is paid in the fixed medical insurance claims comprising special pharmacology.
If exist in the default special medicine logo collection with the matched target identification of the medicine mark, determine the doctor
Factoring is paid in paying for comprising special pharmacology, that is, terminal determines that user has used special medicine, if being not present in the default special medicine logo collection
With the matched target identification of the medicine mark, then terminal determines that user has not used special medicine, does not include spy in medical insurance claims
Pharmacology is paid for;The comparison for passing through medicine mark information in the present embodiment judges to pay in medical insurance claims comprising special pharmacology, so that medical insurance
That audits is more comprehensive.
Further, it on the basis of second embodiment of the invention, proposes the medical insurance analyzed the present invention is based on data and examines
The 3rd embodiment of kernel method.
The present embodiment be in second embodiment after step S22 the step of, in the present embodiment in order to prevent user upload
False audit material, specifically, the medical insurance checking method based on data analysis includes:
Step S25 obtains the User Identity in the Claims Resolution relevant information, inquires default medical data base, obtain
The corresponding disease treatment information of the User Identity;
Terminal obtains the User Identity in the Claims Resolution relevant information, wherein User Identity refers to for only
The identification information of one identification user identity, for example, the account of medical insurance account, user identity demonstrate,proves number, and terminal is based on user identity
Mark inquires default medical data base, wherein and default medical data base refers to the hospital database with terminal communication connection in advance,
Terminal obtains the corresponding disease treatment information of User Identity described in default medical data base.
Step S26 the disease treatment information is compared with the disease information in the Claims Resolution relevant information, to sentence
Whether the Claims Resolution relevant information of breaking is true;
The disease in the disease treatment information and the Claims Resolution relevant information that terminal obtains default medical data base
Information is compared, to judge whether the Claims Resolution relevant information is true, that is, if the disease treatment information and the Claims Resolution phase
The disease information closed in information mismatches, then the Claims Resolution relevant information is untrue;If the disease treatment information and the reason
The disease information matching in relevant information is paid for, then the Claims Resolution relevant information is true.
Step S27 rejects the medical insurance claims if the Claims Resolution relevant information is untrue;
If terminal determines that the Claims Resolution relevant information is untrue, the medical insurance claims are rejected, that is, terminal determines user's
It may include part deceptive information in medical insurance material, medical insurance claims audit does not pass through.
If the Claims Resolution relevant information is true, the medicine mark extracted in the Claims Resolution relevant information is executed, inquiry is pre-
If special medicine logo collection, judge to whether there is and the matched target identification of the medicine mark in the default special medicine logo collection
The step of.It is compared in the present embodiment for by disease treatment information with Claims Resolution relevant information, it is related to realize Claims Resolution
The verifying of the information true and false, so that the audit of medical insurance claims is more comprehensive.
Further, it on the basis of the above embodiment of the present invention, proposes the medical insurance analyzed the present invention is based on data and examines
The fourth embodiment of kernel method.
It is the refinement of step S30 in first embodiment in the present embodiment, if giving the medical insurance claims in the present embodiment
In paid for comprising special pharmacology, then judge whether the special medicine meets the specific implementation of medication rule, it is described based on data analysis
Medical insurance checking method include:
Step S31 obtains the case history note in the Claims Resolution relevant information if paying in the medical insurance claims comprising special pharmacology
Record and prescription information;
If paying in the medical insurance claims comprising special pharmacology, the medical history record and prescription in the Claims Resolution relevant information are obtained
Information, that is, terminal obtains the medical history record and prescription information in Claims Resolution relevant information, with true according to medical history record and prescription information
Determine the practical medication information of user.
Step S32 obtains the practical medication information of the special medicine according to the medical history record and the prescription information;
According to the medical history record and the prescription information in the present embodiment, the practical medication information of the special medicine is obtained
Step is implemented, as follows:
Step a obtains the disease information in the medical history record, and the drug for obtaining spy's medicine described in the prescription information makes
With explanation;
The disease information is compared step b with the drug operation instruction, judges whether the special medicine suits the medicine to the illness;
Step c analyzes the disease information and the drug operation instruction, obtains the spy if spy's medicine is suited the medicine to the illness
The administration time and dosage of medicine, using the administration time and the dosage as practical medication information.
That is, terminal obtains the disease information (disease information: kinds of Diseases, week locating for disease in the medical history record
Phase), terminal determines the special medicine for including in prescription, and obtains the drug operation instruction (drug of spy's medicine described in the prescription information
Operation instruction: including drug variety, drug operation instruction, the purchase dosage of drug);Terminal is by the disease information and the medicine
Product operation instruction is compared, and judges whether the special medicine suits the medicine to the illness;When terminal determines that the special medicine is suited the medicine to the illness, terminal then analyzes institute
State disease information and the drug operation instruction, that is, terminal can determine the medication of patient according to disease information and medicine information
Time, dosage, terminal is using administration time, dosage as practical medication information.
Step S33 inquires default drug and uses rule list, the Standard dose information of the special medicine is obtained, by the reality
Medication information and the Standard dose information are compared;
Terminal inquiry preset drug using rule list (default drug using rule list refer to it is pre-set preserve it is all kinds of
Type spy's medicine uses rule list), terminal obtains the Standard dose information of the special medicine, that is, terminal obtains the drug in medicine information
Title, and inquire default drug and obtain the corresponding Standard dose information of the nomenclature of drug using rule list;Terminal is by the reality
Medication information and the Standard dose information are compared, to judge that special medicine meets medication rule.
That is, terminal uses the practical drug in practical medication information in time, drug usage amount and Standard dose information
Drug be compared using time, drug usage amount, if there is any one mismatch, special medicine does not meet medication rule, defeated
Medical insurance claims audit out does not pass through;If all matchings, special medicine meets medication rule.
Step S34, if the practical medication information and the Standard dose information matches, spy's medicine meets medication rule
Then.
If the practical medication information and the Standard dose information matches, spy's medicine meets medication rule;At this
According to the corresponding illness of special medicine in embodiment, the usage amount using time, special medicine of special medicine is analyzed, and determines that spy's medicine meets use
Medicine rule, to obtain medical insurance claims auditing result, so that medical insurance audit is more comprehensive, accurately.
Further, it on the basis of the above embodiment of the present invention, proposes the medical insurance analyzed the present invention is based on data and examines
5th embodiment of kernel method.
It is in first embodiment after step S20, if being given in the present embodiment in the medical insurance claims in the present embodiment
Not comprising the specific implementation that special pharmacology is paid for, the medical insurance checking method based on data analysis includes:
Step S50 pays for if not including special pharmacology in medical insurance claims, obtains the medical insurance identification information of Claims Resolution relevant information.
If not including special pharmacology in medical insurance claims to pay for, the medical insurance identification information of Claims Resolution relevant information is obtained, that is, terminal is true
Determine the Claims Resolution for not having for special medicine in the medical insurance claims information of user, terminal obtains the medical insurance identification information of Claims Resolution relevant information,
Medical insurance identification information refers to that user buys the identification information of medical insurance, for example, medical insurance is numbered.
Step S60 inquires default medical insurance platform, obtains the corresponding medical insurance declaration form of the medical insurance identification information and described
Medical insurance type in medical insurance declaration form;
Terminal inquiry presets medical insurance platform, and (default medical insurance platform refers to that pre-set HMO Administrator is flat
Platform, wherein record has medical insurance information), terminal obtains the corresponding medical insurance declaration form of medical insurance identification information and the medical insurance is protected
Medical insurance type in list, that is, terminal obtains the medical insurance declaration form of user's purchase in the present embodiment, and determines medical insurance according to medical insurance declaration form
Type.
The medical insurance type is compared step S70 with the Claims Resolution type in the Claims Resolution relevant information;
The medical insurance type is compared terminal with the Claims Resolution type in the Claims Resolution relevant information, and ties according to comparing
Fruit judge user medical insurance claims whether over range, if the medical insurance type and it is described Claims Resolution relevant information in Claims Resolution type
Match, then the medical insurance claims of user do not have over range;It is on the contrary.
Step S80, if the Claims Resolution type matching in the medical insurance type and the Claims Resolution relevant information, exports medical insurance reason
Audit is paid for pass through.
If the Claims Resolution type matching in the medical insurance type and the Claims Resolution relevant information, it is logical to export medical insurance claims audit
It crosses.If the Claims Resolution type in the medical insurance type and the Claims Resolution relevant information mismatches, it is obstructed to export medical insurance claims audit
It crosses, that is, the Claims Resolution of user is not in the range of medical insurance;It is audited in the present embodiment for the medical insurance without special medicine, so that
Medical insurance audit is more comprehensive.
In addition, the embodiment of the present invention also proposes that device, the base are audited in a kind of medical insurance based on data analysis with reference to Fig. 3
Include: in the medical insurance audit device of data analysis
Auditing module 10 is received, the audit for receiving medical insurance claims is requested, and pending Claims Resolution material is obtained;
Analysis judgment module 20 obtains Claims Resolution relevant information for parsing the Claims Resolution material, related according to the Claims Resolution
Information judges whether pay for comprising special pharmacology in the medical insurance claims;
Drug judgment module 30, if judging whether the special medicine accords with for paying in the medical insurance claims comprising special pharmacology
Share medicine rule;
Output module 40 is audited, if meeting medication rule for the special medicine, medical insurance claims audit is exported and passes through.
Optionally, the analysis judgment module 20, comprising:
Feature extraction unit for pre-processing to the Claims Resolution material, and extracts the Claims Resolution material after pretreatment
Characteristic information in material;
Character recognition unit obtains character information, and will for the characteristic information to be input to preset characters classifier
The character information is post-processed, and Claims Resolution relevant information is obtained;
Information comparison unit inquires default special medicine identification sets for extracting the medicine mark in the Claims Resolution relevant information
It closes, judges to whether there is and the matched target identification of the medicine mark in the default special medicine logo collection;
Judging unit is compared, if for existing and the matched target of the medicine mark in the default special medicine logo collection
Mark then determines to pay in the medical insurance claims comprising special pharmacology.
Optionally, the analysis judgment module 20, comprising:
Information acquisition unit inquires default medical number for obtaining the User Identity in the Claims Resolution relevant information
According to library, the corresponding disease treatment information of the User Identity is obtained;
Information judging unit, for carrying out the disease information in the disease treatment information and the Claims Resolution relevant information
It compares, to judge whether the Claims Resolution relevant information is true;
Unit is rejected, if untrue for the Claims Resolution relevant information, rejects the medical insurance claims;
Information comparison unit is executed and is extracted in the Claims Resolution relevant information if true for the Claims Resolution relevant information
Medicine mark, inquire default special medicine logo collection, judge to whether there is in the default special medicine logo collection and the drug
The step of identifying matched target identification.
Optionally, the drug judgment module 30, comprising:
Acquisition of information submodule, if obtaining the related letter of the Claims Resolution for paying in the medical insurance claims comprising special pharmacology
Medical history record and prescription information in breath;
Medication information generates submodule, for obtaining the special medicine according to the medical history record and the prescription information
Practical medication information;
Inquiry compares submodule, uses rule list for inquiring default drug, obtains the Standard dose information of the special medicine,
The practical medication information and the Standard dose information are compared;
It matches and determines submodule, if being used for the practical medication information and the Standard dose information matches, the spy
Medicine meets medication rule.
Optionally, the medication information generates submodule, comprising:
Acquiring unit obtains spy's medicine described in the prescription information for obtaining the disease information in the medical history record
Drug operation instruction;
Contrast judgement unit judges the spy for the disease information to be compared with the drug operation instruction
Whether medicine suits the medicine to the illness;
Medication generation unit analyzes the disease information and the drug operation instruction if suiting the medicine to the illness for the special medicine,
The administration time and dosage of the special medicine are obtained, using the administration time and the dosage as practical medication information.
Optionally, auditing module 10 is received, comprising:
Output unit is received, the audit for receiving medical insurance claims is requested, and upload material prompt information is exported, to prompt to use
Family uploads the corresponding electronic document of medical insurance claims;
Judging unit is received, the electronic document uploaded for receiving the user judges whether the electronic document meets
Default screening rule;
Uploading unit is prompted to export prompt information if not meeting the default screening rule for the electronic document,
To prompt the user to upload again;
Acquiring unit, if meeting the default screening rule for the electronic document, using the electronic document as
Pending Claims Resolution material.
Optionally, device is audited in the medical insurance based on data analysis, comprising:
Medical insurance obtains module, if paying for for not including special pharmacology in medical insurance claims, obtains the medical insurance of Claims Resolution relevant information
Identification information;
Declaration form enquiry module obtains the corresponding medical insurance of the medical insurance identification information for inquiring default medical insurance platform
Medical insurance type in declaration form and the medical insurance declaration form;
Comparison module, for the medical insurance type to be compared with the Claims Resolution type in the Claims Resolution relevant information;
Audit passes through module, if for the Claims Resolution type matching in the medical insurance type and the Claims Resolution relevant information,
Output medical insurance claims audit passes through.
Wherein, the step of each Implement of Function Module of the medical insurance audit device based on data analysis can refer to base of the present invention
In each embodiment of the medical insurance checking method of data analysis, details are not described herein again.
In addition, the embodiment of the present invention also proposes a kind of computer storage medium.
Computer program, the realization when computer program is executed by processor are stored in the computer storage medium
Operation in medical insurance checking method provided by the above embodiment based on data analysis.
It should be noted that, in this document, relational terms such as first and second and the like are used merely to a reality
Body/operation/object is distinguished with another entity/operation/object, without necessarily requiring or implying these entity/operations/
There are any actual relationship or orders between object;The terms "include", "comprise" or its any other variant meaning
Covering non-exclusive inclusion, so that the process, method, article or the system that include a series of elements not only include that
A little elements, but also including other elements that are not explicitly listed, or further include for this process, method, article or
The intrinsic element of system.In the absence of more restrictions, the element limited by sentence "including a ...", is not arranged
Except there is also other identical elements in process, method, article or the system for including the element.
For device embodiment, since it is substantially similar to the method embodiment, related so describing fairly simple
Place illustrates referring to the part of embodiment of the method.The apparatus embodiments described above are merely exemplary, wherein making
It may or may not be physically separated for the unit of separate part description.In can selecting according to the actual needs
Some or all of the modules realize the purpose of the present invention program.Those of ordinary skill in the art are not making the creative labor
In the case where, it can it understands and implements.
The serial number of the above embodiments of the invention is only for description, does not represent the advantages or disadvantages of the embodiments.
Through the above description of the embodiments, those skilled in the art can be understood that above-described embodiment side
Method can be realized by means of software and necessary general hardware platform, naturally it is also possible to by hardware, but in many cases
The former is more preferably embodiment.Based on this understanding, technical solution of the present invention substantially in other words does the prior art
The part contributed out can be embodied in the form of software products, which is stored in one as described above
In storage medium (such as ROM/RAM, magnetic disk, CD), including some instructions are used so that terminal device (it can be mobile phone,
Computer, server, air conditioner or network equipment etc.) execute method described in each embodiment of the present invention.
The above is only a preferred embodiment of the present invention, is not intended to limit the scope of the invention, all to utilize this hair
Equivalent structure or equivalent flow shift made by bright specification and accompanying drawing content is applied directly or indirectly in other relevant skills
Art field, is included within the scope of the present invention.
Claims (10)
1. a kind of medical insurance checking method based on data analysis, which is characterized in that the medical insurance audit side based on data analysis
Method the following steps are included:
The audit request for receiving medical insurance claims, obtains pending Claims Resolution material;
Parse the Claims Resolution material obtain Claims Resolution relevant information, judged according to the Claims Resolution relevant information be in the medical insurance claims
It is no to be paid for comprising special pharmacology;
If paying in the medical insurance claims comprising special pharmacology, judge whether the special medicine meets medication rule;
If spy's medicine meets medication rule, exports medical insurance claims audit and pass through.
2. the medical insurance checking method as described in claim 1 based on data analysis, which is characterized in that the parsing Claims Resolution
Whether material obtains Claims Resolution relevant information, judged in the medical insurance claims according to the Claims Resolution relevant information comprising special pharmacology compensation
Step, comprising:
The Claims Resolution material is pre-processed, and extracts the characteristic information in the Claims Resolution material after pretreatment;
The characteristic information is input to preset characters classifier, obtains character information, and will be after character information progress
Reason obtains Claims Resolution relevant information;
The medicine mark in the Claims Resolution relevant information is extracted, default special medicine logo collection is inquired, judges the default special medicine mark
Knowing in set whether there is and the matched target identification of the medicine mark;
If exist in the default special medicine logo collection with the matched target identification of the medicine mark, determine the medical insurance reason
It is paid in compensation comprising special pharmacology.
3. the medical insurance checking method as claimed in claim 2 based on data analysis, which is characterized in that described to believe the feature
Breath is input to preset characters classifier, obtains character information, and the character information is post-processed, and obtains related letter of settling a claim
After the step of breath, comprising:
The User Identity in the Claims Resolution relevant information is obtained, default medical data base is inquired, obtains the user identity
Identify corresponding disease treatment information;
The disease treatment information is compared with the disease information in the Claims Resolution relevant information, to judge the Claims Resolution phase
Whether true close information;
If the Claims Resolution relevant information is untrue, the medical insurance claims are rejected;
If the Claims Resolution relevant information is true, the medicine mark extracted in the Claims Resolution relevant information is executed, default spy is inquired
Medicine logo collection judges in the default special medicine logo collection with the presence or absence of the step with the matched target identification of the medicine mark
Suddenly.
4. the medical insurance checking method as described in claim 1 based on data analysis, which is characterized in that if the medical insurance is managed
It is paid in compensation comprising special pharmacology, then judges whether the special medicine meets the step of medication rule, comprising:
If paying in the medical insurance claims comprising special pharmacology, the medical history record and prescription letter in the Claims Resolution relevant information are obtained
Breath;
According to the medical history record and the prescription information, the practical medication information of the special medicine is obtained;
It inquires default drug and uses rule list, the Standard dose information of the special medicine is obtained, by the practical medication information and institute
Standard dose information is stated to be compared;
If the practical medication information and the Standard dose information matches, spy's medicine meets medication rule.
5. the medical insurance checking method as claimed in claim 4 based on data analysis, which is characterized in that described according to the case history
Record and the prescription information, the step of obtaining the practical medication information of the special medicine, comprising:
The disease information in the medical history record is obtained, the drug operation instruction of spy's medicine described in the prescription information is obtained;
The disease information is compared with the drug operation instruction, judges whether the special medicine suits the medicine to the illness;
If spy's medicine is suited the medicine to the illness, the disease information and the drug operation instruction are analyzed, when obtaining the medication of the special medicine
Between and dosage, using the administration time and the dosage as practical medication information.
6. the medical insurance checking method as described in claim 1 based on data analysis, which is characterized in that the reception medical insurance claims
Audit request, the step of obtaining pending Claims Resolution material, comprising:
The audit request for receiving medical insurance claims, exports upload material prompt information, corresponding to prompt user to upload medical insurance claims
Electronic document;
The electronic document that the user uploads is received, judges whether the electronic document meets default screening rule;
If the electronic document does not meet the default screening rule, export prompt information, with prompt the user again on
It passes;
If the electronic document meets the default screening rule, using the electronic document as pending Claims Resolution material.
7. the medical insurance checking method as described in claim 1 based on data analysis, which is characterized in that the parsing Claims Resolution
Whether material obtains Claims Resolution relevant information, judged in the medical insurance claims according to the Claims Resolution relevant information comprising special pharmacology compensation
After step, comprising:
If not including special pharmacology in medical insurance claims to pay for, the medical insurance identification information of Claims Resolution relevant information is obtained;
Default medical insurance platform is inquired, is obtained in the corresponding medical insurance declaration form of the medical insurance identification information and the medical insurance declaration form
Medical insurance type;
The medical insurance type is compared with the Claims Resolution type in the Claims Resolution relevant information;
If the Claims Resolution type matching in the medical insurance type and the Claims Resolution relevant information exports medical insurance claims audit and passes through.
8. device is audited in a kind of medical insurance based on data analysis, which is characterized in that dress is audited in the medical insurance based on data analysis
It sets and includes:
Auditing module is received, the audit for receiving medical insurance claims is requested, and pending Claims Resolution material is obtained;
Analysis judgment module obtains Claims Resolution relevant information for parsing the Claims Resolution material, is sentenced according to the Claims Resolution relevant information
Break and whether is paid for comprising special pharmacology in the medical insurance claims;
Drug judgment module, if judging whether the special medicine meets medication for paying in the medical insurance claims comprising special pharmacology
Rule;
Output module is audited, if meeting medication rule for the special medicine, medical insurance claims audit is exported and passes through.
9. equipment is audited in a kind of medical insurance based on data analysis, which is characterized in that the medical insurance audit based on data analysis is set
It is standby to include: memory, processor and be stored in the computer program that run on the memory and on the processor,
In:
When the computer program is executed by the processor realize as described in any one of claims 1 to 7 based on data
The step of medical insurance checking method of analysis.
10. a kind of computer storage medium, which is characterized in that be stored with computer program, institute in the computer storage medium
State the medical insurance based on data analysis realized as described in any one of claims 1 to 7 when computer program is executed by processor
The step of checking method.
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CN201811529288.6A CN109670788A (en) | 2018-12-13 | 2018-12-13 | Medical insurance checking method, device, equipment and storage medium based on data analysis |
PCT/CN2019/096012 WO2020119116A1 (en) | 2018-12-13 | 2019-07-15 | Medical insurance auditing method, apparatus and device based on data analysis, and storage medium |
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