CN110992191A - Medical insurance claim settlement information processing method, device, equipment and storage medium - Google Patents
Medical insurance claim settlement information processing method, device, equipment and storage medium Download PDFInfo
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- CN110992191A CN110992191A CN201911163818.4A CN201911163818A CN110992191A CN 110992191 A CN110992191 A CN 110992191A CN 201911163818 A CN201911163818 A CN 201911163818A CN 110992191 A CN110992191 A CN 110992191A
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- G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
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Abstract
The invention provides a medical insurance claim settlement information processing method, a device, equipment and a storage medium, wherein a medical expense claim settlement request uploaded through a first claim settlement way or a second claim settlement way is received, and the medical expense claim settlement request comprises user diagnosis information; acquiring the medical service items covered by the user and the remaining claim settlement amount information from the database according to the diagnosis information of the user; determining information of the amount of money to be paid and/or information of the amount of money required to be borne by the user in the total medical expense consumed by the user according to the information of the doctor of the user, the medical service items covered and protected by the user and the information of the remaining amount of money to be paid; and outputting information of the amount to be paid and/or information of the amount to be borne by the user. The method has the advantages that the method can facilitate the user to carry out the claim settlement of medical insurance by providing various claim settlement approaches, save the time of the user and improve the user experience; meanwhile, the time efficiency of processing the claim cases by the insurance company can be improved, the labor cost is saved, and the accurate claim settlement of the claim cases in various claim settlement ways is realized.
Description
Technical Field
The invention relates to the technical field of communication, in particular to a medical insurance claim settlement information processing method, device, equipment and storage medium.
Background
As people pay more and more attention to health, more and more people buy medical insurance, and after medical expenses are generated when the insured person is ill and has a doctor, the insurance institution can apply for claim settlement through a claim settlement program and give certain economic compensation to the insurance institution.
At present, the claim settlement procedure usually includes that the insured person registers in a hospital, pays all medical expenses after visiting a doctor, applies for the claim settlement to the insurance company and submits the application material of the claim settlement, and the insurance company pays the claim settlement money after passing the audit. The existing claim settlement program is low in efficiency, needs to consume more labor cost, is single in claim settlement application mode, wastes time of security personnel, and causes low user experience.
Disclosure of Invention
The embodiment of the invention provides a method, a device, equipment and a storage medium for processing medical insurance claim settlement information, which can provide multiple claim settlement approaches to facilitate the user to settle the claim of medical insurance, save the time of the user, improve the timeliness of an insurance company for processing claim settlement cases and save the labor cost.
The first aspect of the embodiment of the present invention provides a method for processing medical insurance claim settlement information, which is applied to a medical insurance claim settlement system server, and the method includes:
receiving a medical expense claim settlement request uploaded by a terminal device of a medical institution through a first claim settlement way, or receiving a medical expense claim settlement request uploaded by a terminal device of a user or a terminal device of an insurance company through a second claim settlement way, wherein the medical expense claim settlement request comprises the information of the doctor visit of the user;
acquiring the medical service items covered by the user and the remaining claim settlement amount information from a database according to the diagnosis information of the user;
determining information of the amount of money to be paid and/or information of the amount of money required to be borne by the user in the total medical expense consumed by the user according to the information of the doctor of the user, the medical service items borne by the user and the information of the remaining amount of money to be paid;
and sending the information of the amount to be paid and/or the information of the amount to be borne by the user to at least one of the terminal equipment of the medical institution, the terminal equipment of the user and the terminal equipment of the insurance company according to the way of the claim settlement.
A second aspect of an embodiment of the present invention provides a medical insurance claim settlement information processing apparatus, including:
the receiving module is used for receiving a medical expense claim settlement request uploaded by terminal equipment of a medical institution through a first claim settlement way, or receiving a medical expense claim settlement request uploaded by terminal equipment of a user or terminal equipment of an insurance company through a second claim settlement way, wherein the medical expense claim settlement request comprises user diagnosis information;
the query module is used for acquiring the medical service items covered by the user and the residual claim settlement amount information from the database according to the diagnosis information of the user;
the processing module is used for determining information of the amount of money to be paid and/or information of the amount of money required to be borne by the user in the total medical expense consumed by the user according to the information of the patient visit of the user, the medical service items covered by the user and the information of the remaining amount of money to be paid;
and the output module is used for sending the information of the amount to be paid and/or the information of the amount required to be borne by the user to at least one of terminal equipment of a medical institution, the terminal equipment of the user and the terminal equipment of an insurance company according to a claim settlement way.
A third aspect of an embodiment of the present invention provides a medical insurance claim settlement information processing apparatus, including:
a memory;
a processor; and
a computer program;
wherein the computer program is stored in the memory and configured to be executed by the processor to implement the method of the first aspect.
A fourth aspect of embodiments of the present invention is to provide a computer-readable storage medium having stored thereon a computer program;
which when executed by a processor implements the method according to the first aspect.
According to the medical insurance claim settlement information processing method, device, equipment and storage medium provided by the embodiment of the invention, a medical expense claim settlement request uploaded by a terminal device of a medical institution through a first claim settlement way is received, or a medical expense claim settlement request uploaded by a terminal device of a user or a terminal device of an insurance company through a second claim settlement way is received, wherein the medical expense claim settlement request comprises user diagnosis information; acquiring the medical service items covered by the user and the remaining claim settlement amount information from a database according to the diagnosis information of the user; determining information of the amount of money to be paid and/or information of the amount of money required to be borne by the user in the total medical expense consumed by the user according to the information of the doctor of the user, the medical service items borne by the user and the information of the remaining amount of money to be paid; and sending the information of the amount to be paid and/or the information of the amount to be borne by the user to at least one of the terminal equipment of the medical institution, the terminal equipment of the user and the terminal equipment of the insurance company according to the way of the claim settlement. The method has the advantages that the method can facilitate the user to carry out the claim settlement of medical insurance by providing various claim settlement approaches, save the time of the user and improve the user experience; meanwhile, the time efficiency of processing the claim cases by the insurance company can be improved, the labor cost is saved, and the accurate claim settlement of the claim cases in various claim settlement ways is realized.
Drawings
In order to more clearly illustrate the embodiments of the present invention or the technical solutions in the prior art, the drawings used in the description of the embodiments or the prior art will be briefly described below, and it is obvious that the drawings in the following description are only some embodiments of the present invention, and for those skilled in the art, other drawings can be obtained according to these drawings without creative efforts.
Fig. 1 is a communication system architecture diagram of a medical insurance claim settlement information processing method according to an embodiment of the present invention;
fig. 2 is a flowchart of a method for processing medical insurance claim settlement information according to an embodiment of the present invention;
fig. 3 is a flowchart of a method for processing medical insurance claim settlement information according to another embodiment of the present invention;
fig. 4 is a block diagram of a medical insurance claim settlement information processing apparatus according to an embodiment of the present invention;
fig. 5 is a block diagram of a medical insurance claim information processing apparatus according to an embodiment of the present invention.
Detailed Description
The technical solutions in the embodiments of the present invention will be clearly and completely described below with reference to the drawings in the embodiments of the present invention, and it is obvious that the described embodiments are only a part of the embodiments of the present invention, and not all of the embodiments. All other embodiments, which can be derived by a person skilled in the art from the embodiments given herein without making any creative effort, shall fall within the protection scope of the present invention.
The terms "first", "second", etc. are used for descriptive purposes only and are not to be construed as indicating or implying relative importance or implicitly indicating the number of technical features indicated.
The medical insurance claim settlement information processing method provided by the invention can be applied to the communication system shown in fig. 1. As shown in fig. 1, the communication system includes a medical insurance claim settlement system server 10 of an insurance company, a terminal device 11 of a medical institution, a terminal device 12 of a user, and a terminal device 13 of the insurance company, where the medical insurance claim settlement system server of the insurance company may be a server, a server cluster composed of several servers, or a cloud computing service center; the terminal devices 11 of the medical institutions and the terminal devices 13 of the insurance companies may include, but are not limited to, devices such as personal computers, smart phones, tablets, personal digital assistants, servers, and the like, and the terminal devices 12 of the users may also include, but are not limited to, devices such as personal computers, smart phones, tablets, personal digital assistants, wearable devices, and the like.
In the embodiment of the invention, at least two ways for settling the claim are provided for the insured person (user) to settle the claim for medical expenses. In the first claim settlement approach, the user can make a appointment for a visit through the user terminal device 12, before the visit is completed and medical expenses are paid, the medical expense claim settlement request is uploaded to the medical insurance claim settlement system server 10 by the medical institution terminal device 11, the medical expense claim settlement request includes the user visit information, then the medical insurance claim settlement system server 10 determines the information of the amount of money to be paid and/or the information of the amount of money required to be borne by the user in the total medical expenses consumed by the user this time, then the information of the amount of money to be paid and/or the information of the amount of money required to be borne by the user is sent to the medical institution terminal device 11 and/or the user terminal device 12, and then the user performs payment operation according to the information of the amount required to be borne by the user without a subsequent claim process; in the second settlement route, the user completes the visit and pays the whole medical expense firstly, then applies for settlement, the terminal device 12 of the user or the terminal device 13 of the insurance company uploads a medical expense settlement request to the medical insurance settlement system server 10, the medical expense settlement request comprises the visit information of the user, then the medical insurance settlement system server 10 determines the information of the amount of money to be paid and/or the information of the amount of money to be paid by the user in the total medical expense consumed by the user this time, and then the information of the amount of money to be paid and/or the information of the amount of money to be paid by the user is sent to the terminal device 13 of the insurance company, or simultaneously sent to the terminal device 13 of the insurance company and the terminal device 12 of the user, and finally the insurance company pays the amount of money to be paid according to the information of the amount of money to be paid. The medical insurance claim settlement information processing method provided by the embodiment of the invention can be applied to various types of medical insurance such as common medical insurance, accidental injury medical insurance, hospitalization medical insurance, dental insurance and the like.
The following describes the process of processing the medical insurance claim information in detail with reference to specific embodiments.
Fig. 2 is a flowchart of a medical insurance claim settlement information processing method according to an embodiment of the present invention. The embodiment provides a medical insurance claim settlement information processing method, the execution subject of which is a medical insurance claim settlement system server of an insurance company, the medical insurance claim settlement information processing method comprises the following specific steps:
s201, receiving a medical expense claim settlement request uploaded by a terminal device of a medical institution through a first claim settlement way, or receiving a medical expense claim settlement request uploaded by a terminal device of a user or a terminal device of an insurance company through a second claim settlement way, wherein the medical expense claim settlement request comprises user treatment information.
In this embodiment, the medical insurance claim settlement system provides at least two ways for the insured person (user) to settle the medical expenses, wherein in the first way, the user can directly deduct the amount to be paid in the total medical expenses consumed this time before paying the medical expenses, and then only pay the amount charged by the user; in the second claim settlement approach, the user can pay the total medical expenses for the current consumption first, then apply for claim settlement of the medical expenses, and pay the amount of the claim settlement by the insurance company. As an alternative embodiment, the first claim settlement route may be a claim settlement route of a private hospital, and the second claim settlement route may be a claim settlement route of a public hospital. Of course, this embodiment may also support other claim approaches besides the two listed above, and will not be described herein again.
In both the first claim settlement approach and the second claim settlement approach, a medical expense claim settlement request needs to be uploaded to the medical insurance claim settlement system server, wherein the medical expense claim settlement request at least includes user treatment information, and specifically, the user treatment information includes, but is not limited to, charging documents, medical records, diagnosis books, laboratory certificates, social security cards, identity documents, and the like.
S202, acquiring the medical service items covered by the user and the remaining claim settlement amount information from the database according to the user diagnosis information.
In this embodiment, the medical insurance claim settlement system server shares the claim amount paid in different claim routes through the database, for example, the total amount of medical insurance purchased by the user can be 10000 yuan, the claim amount paid by the user through the second claim route is 4000 yuan, the claim amount paid in the second claim route can be recorded in the database, and the remaining claim amount can also be recorded as 6000, so that the user can determine the claim amount paid in the first claim route as 4000 yuan and the remaining claim amount as 6000 through the database, and conversely, the claim amount paid and the remaining claim amount can also be queried in the database when performing claim through the second claim route, thereby realizing the sharing of the claim amount in different claim routes.
S203, determining information of the amount of money to be paid and/or information of the amount of money required to be borne by the user in the total medical expense consumed this time according to the information of the doctor visit of the user, the medical service items covered by the user and the information of the remaining amount of money to be paid.
In this embodiment, after acquiring the medical service item covered by the user and the remaining claim amount information, the medical service item for the current visit may be proposed from the visit information of the user, and it is determined whether the medical service item for the current visit belongs to the medical service item covered by the user, and if so, the claim amount that the insurance company should pay for the user in the total medical cost of the current consumption may be determined, and the amount that needs to be borne by the user, that is, the self-payment amount of the user may also be determined. Specifically, the following procedure may be adopted:
and if the diagnosis item contained in the user diagnosis information belongs to the medical service item covered by the user, determining the information of the amount to be paid according to the remaining claim amount information or deducting the amount to be paid from the total medical expense consumed by the user this time to obtain the information of the amount to be borne by the user.
That is, firstly, it is determined which of the medical treatment items that the user visits at this time belong to the medical service items covered by the user, for the medical treatment items that belong to the medical service items covered by the user, the corresponding medical expenses can be determined, the highest amount to be paid is calculated according to the predetermined medical insurance claim payment proportion, and then the actual amount to be paid is determined according to the remaining claim amount information, that is, if the remaining claim amount is greater than or equal to the above-mentioned highest amount to be paid, the highest amount to be paid is taken as the amount to be paid, and if the remaining claim amount is less than the above-mentioned highest amount to be paid, the remaining claim amount is taken as the amount to be paid. For example, the visit items of the user at the present visit include tooth extraction and tooth washing, wherein the tooth washing cost is 200 yuan, the tooth extraction cost is 500 yuan, the tooth washing does not belong to the medical service item protected by the user, the tooth extraction belongs to the medical service item protected by the user, the medical insurance claim payment proportion is 80%, it is determined that 500 × 80% of the maximum claim for tooth extraction is 400 yuan, if the remaining claim amount of the user is 300 yuan, only 300 yuan of the user can be paid at this time, that is, the claim amount is 300 yuan, the user charge amount for the present visit is 200+500 yuan 300 yuan or 400 yuan, and the remaining claim amount of the user is 0 yuan at this time; if the remaining claim amount of the user is 500 yuan, the highest 400 yuan can be paid, that is, the payment amount to be paid is 400 yuan, the user account amount of the visit is 200+500 and 400 yuan is 300 yuan, and the remaining claim amount of the user is 500 and 400 yuan is 100 yuan.
And S204, sending the information of the amount to be paid and/or the information of the amount to be borne by the user to at least one of the terminal equipment of the medical institution, the terminal equipment of the user and the terminal equipment of the insurance company according to a claim settlement way.
In this embodiment, after the information of the amount to be paid and/or the information of the amount of money required to be assumed by the user are obtained, the information of the amount to be paid and/or the information of the amount of money required to be assumed by the user may be output.
Specifically, for the first claim settlement approach, the information of the amount of money to be borne by the user can be sent to the terminal equipment of the medical institution and/or the terminal equipment of the user, and then the user performs payment operation according to the information of the amount of money to be borne by the user without a subsequent claim settlement process; for the second claim settlement approach, the information of the amount to be paid can be sent to the terminal device of the insurance company, optionally, the information of the amount to be paid can also be sent to the terminal device of the insurance company and the terminal device of the user at the same time, and then the insurance company pays the amount to be paid to the user according to the information of the amount to be paid.
On the basis of the above embodiment, the method further includes: and after the claim is finished, updating the remaining claim amount information in the database according to the information of the amount to be paid. In this embodiment, the remaining claim amount information of each claim path is shared in the database, and the database is updated each time the claim process is completed, so that accurate recording of the remaining claim amount information can be realized, and accurate claim of claim cases in multiple claim paths can be realized.
In the method for processing medical insurance claim settlement information provided by this embodiment, a medical expense claim settlement request uploaded by a terminal device of a medical institution through a first claim settlement way is received, or a medical expense claim settlement request uploaded by a terminal device of a user or a terminal device of an insurance company through a second claim settlement way is received, where the medical expense claim settlement request includes user visit information; acquiring the medical service items covered by the user and the remaining claim settlement amount information from a database according to the diagnosis information of the user; determining information of the amount of money to be paid and/or information of the amount of money required to be borne by the user in the total medical expense consumed by the user according to the information of the doctor of the user, the medical service items borne by the user and the information of the remaining amount of money to be paid; and sending the information of the amount to be paid and/or the information of the amount to be borne by the user to at least one of the terminal equipment of the medical institution, the terminal equipment of the user and the terminal equipment of the insurance company according to the way of the claim settlement. The method has the advantages that the method can facilitate the user to carry out the claim settlement of medical insurance by providing various claim settlement approaches, save the time of the user and improve the user experience; meanwhile, the time efficiency of processing the claim cases by the insurance company can be improved, the labor cost is saved, and the accurate claim settlement of the claim cases in various claim settlement ways is realized.
On the basis of the above embodiments, the claim settlement process of the first claim settlement approach is described in detail in this embodiment, wherein the first claim settlement approach is a claim settlement approach for performing claim settlement before paying medical expenses for the user.
In this embodiment, after the user completes the visit, the medical institution sends a medical expense claim settlement request to the medical insurance claim settlement system server of the insurance company through the terminal device of the medical institution, and the medical expense claim settlement request includes the user visit information.
That is, in the embodiment S201, receiving the medical expense claim settlement request uploaded by the terminal device of the medical institution through the first claim settlement approach specifically includes: a request for a claim for medical expenses uploaded by a terminal device of a medical institution before a user pays a medical expense is received.
Further, after receiving a medical expense claim settlement request uploaded by a terminal device of a medical institution, a medical insurance claim settlement system server of an insurance company acquires a medical service item and remaining claim amount information of a user from a database according to the user diagnosis information; determining information of the amount of money to be paid and/or information of the amount of money required to be borne by the user in the total medical expense consumed by the user according to the information of the doctor of the user, the medical service items borne by the user and the information of the remaining amount of money to be paid; then the medical insurance claim settlement system server of the insurance company sends the information of the amount of money required to be undertaken by the user to the terminal equipment of the medical institution and/or the terminal equipment of the user; and finally, the user performs payment operation according to the information of the amount of money borne by the user, and the user does not need to perform a claim settlement process subsequently.
On the basis of the above embodiment, as shown in fig. 3, before the receiving a medical expense claim settlement request uploaded by a terminal device of a medical institution before the user pays a medical expense, the first claim settlement approach may further include:
s301, receiving a diagnosis appointment request sent by terminal equipment of a user;
s302, inquiring the medical service item and/or the residual claim amount information covered by the user from the database according to the diagnosis reservation request, and sending the medical service item and/or the residual claim amount information covered by the user to the terminal equipment of the user.
In this embodiment, the user may make a diagnosis appointment through the terminal device thereof, and when the diagnosis appointment is made, the user may actively query the medical service items and/or the remaining claim settlement amount information covered by the user through the terminal device thereof, or the medical insurance claim settlement system server of the insurance company may actively push the information to the terminal device of the user, or certainly, the user may query other medical insurance related information, which is not described herein again. Furthermore, the appointment can be made according to the visit appointment request, and the appointment result is returned to the terminal equipment of the user.
Further, in this embodiment, the medical insurance claim settlement system server of the insurance company may also verify the user information after receiving the appointment request for medical consultation, and determine the medical service item and/or remaining claim amount information covered by the user, so that the amount information required to be borne by the user can be quickly determined after receiving the medical expense claim settlement request uploaded by the terminal device of the medical institution, the processing speed is increased, and the user waiting time is reduced.
On the basis of the above embodiments, the present embodiment describes in detail the claim settlement process of the second claim settlement approach in detail, wherein the second claim settlement approach is a claim settlement approach for performing claim settlement after the user pays the medical expense.
In this embodiment, when the user finishes his visit, he pays the entire medical fee and then issues a claim to the insurance company. Specifically, in an optional embodiment, the user may submit the user visit information such as a charging bill, a medical record, a diagnostic book, a laboratory sheet, a social security card, an identity document, and the like to the insurance company, and the insurance company service staff uploads a medical expense claim settlement request to a medical insurance claim settlement system server of the insurance company through the terminal device of the insurance company, wherein the medical expense claim settlement request includes the user visit information. In another alternative embodiment, the user can also upload a medical expense claim settlement request to a medical insurance claim settlement system server of the insurance company through the terminal device of the user, wherein the medical expense claim settlement request comprises the diagnosis information of the user.
That is, in the above embodiment, the receiving of the medical expense claim settlement request uploaded by the terminal device of the user or the terminal device of the insurance company through the second claim settlement approach in S201 specifically includes: and receiving a medical expense settlement request uploaded by the terminal equipment of the user or the terminal equipment of the insurance company after the user pays the medical expense.
Further, after receiving a medical expense claim settlement request uploaded by the terminal equipment of the user or the terminal equipment of the insurance company, the medical insurance claim settlement system server of the insurance company can acquire the medical service items and the remaining claim settlement amount information covered by the user from the database according to the diagnosis information of the user after being checked; determining information of the amount of money to be paid and/or information of the amount of money required to be borne by the user in the total medical expense consumed by the user according to the information of the doctor of the user, the medical service items borne by the user and the information of the remaining amount of money to be paid; then the medical insurance claim settlement system server of the insurance company sends the information of the amount of money to be paid to the terminal equipment of the insurance company, or simultaneously sends the information of the amount of money to be paid to the terminal equipment of the insurance company and the terminal equipment of the user; and finally, paying the claim payment amount to the user by the insurance company according to the claim payment amount information.
For more clearly explaining the above embodiments, the present embodiment is exemplified as follows (for illustration only, not representing the true situation):
the method comprises the steps that a small beauty mother purchases child dental insurance for a daughter small beauty, teeth of the small beauty need to be treated in an insurance period, a patient is registered in a public hospital for treatment, the mother pays all medical expenses after the treatment, the mother needs to actively apply for claim settlement and submits claim settlement application materials to an insurance company, insurance company business personnel upload a medical expense claim settlement request to a medical insurance claim settlement system server of the insurance company through terminal equipment of the insurance company, after the examination is passed, the medical insurance company medical insurance claim settlement system server outputs claim settlement amount information, the insurance company pays mother's money according to the claim amount information, the remaining claim amount information in a database is updated, and the claim settlement process is finished.
One month later, the Xiaomei again has dental diseases and needs to go to a hospital for treatment, the mother initiates an on-line private hospital appointment through the terminal device (for example, the private hospital appointment is conducted through a mobile phone for payment treasures/telephone), the appointment page can inquire whether the Xiaomei is a dental insurance product client of an insurance company and inquire an effective policy under the name of the Xiaomei for appointment, after treatment, the private hospital enters the user attendance information such as actual treatment items and the like into a medical insurance claim system server of the insurance company through the terminal device, a medical expense claim request is uploaded, the medical insurance claim system server of the insurance company outputs information of the amount to be paid and/or information of the amount to be borne by the user to the terminal device of the private hospital, the private hospital completes direct claim service, the insurance company can directly deduct the claim part, and the mother only pays the rest part (the amount to be borne by the user), the related claim data is submitted to the insurance company by the private hospital, and the client can realize one-stop service of seeing a doctor and finishing claim settlement on the same day. And after the claim settlement is finished, the remaining claim settlement amount information in the database can be updated, and the claim settlement process is ended.
Through the claim settlement process, the process and time of claim settlement of the young mamma can be saved, the labor cost of operating personnel of an insurance company for processing claim settlement cases is saved, the claim settlement timeliness is improved, and the effects of common claim settlement in multiple ways and accurate claim settlement are achieved.
Fig. 4 is a block diagram of a medical insurance claim information processing apparatus according to an embodiment of the present invention. The medical insurance claim information processing apparatus provided in this embodiment can execute the processing flow provided in the embodiment of the medical insurance claim information processing method, and as shown in fig. 4, the medical insurance claim information processing apparatus 400 includes a receiving module 41, an inquiring module 42, a processing module 43, and an output module 44.
The receiving module 41 is configured to receive a medical expense claim settlement request uploaded by a terminal device of a medical institution through a first claim settlement approach, or receive a medical expense claim settlement request uploaded by a terminal device of a user or a terminal device of an insurance company through a second claim settlement approach, where the medical expense claim settlement request includes user visit information;
the query module 42 is used for acquiring the medical service terms covered by the user and the remaining claim settlement amount information from the database according to the diagnosis information of the user;
the processing module 43 is configured to determine information of a payable amount in the total medical cost of the current consumption of the user and/or information of an amount required to be borne by the user according to the user visit information, the medical service items covered by the user and the remaining claim amount information;
and the output module 44 is used for sending the information of the amount of money to be paid and/or the information of the amount of money required to be borne by the user to at least one of the terminal equipment of the medical institution, the terminal equipment of the user and the terminal equipment of the insurance company according to the way of claim settlement.
On the basis of the embodiment, the first claim settlement way is a claim settlement way for settlement before the user pays medical expenses;
when receiving the medical expense claim settlement request uploaded by the terminal device of the medical institution through the first claim settlement approach, the receiving module 41 is configured to:
a request for a claim for medical expenses uploaded by a terminal device of a medical institution before a user pays a medical expense is received.
On the basis of the above embodiment, for the first claim settlement approach, before the receiving of the claim settlement request uploaded by the terminal device of the medical institution before the user pays the medical fee, the receiving module 41 is further configured to receive a visit reservation request sent by the terminal device of the user;
the query module 42 is further configured to query the medical service terms covered by the user and/or the remaining claim amount information from the database according to the visit appointment request;
the output module 44 is further configured to send the information of the medical service items covered by the user and/or the remaining claim amount to the terminal device of the user.
On the basis of the above embodiment, the second claim settlement approach is a claim settlement approach for settling a claim after a user pays a medical expense;
before receiving the medical expense claim settlement request uploaded by the terminal device of the user or the terminal device of the insurance company through the second claim settlement approach, the receiving module 41 is further configured to:
and receiving a medical expense settlement request uploaded by the terminal equipment of the user or the terminal equipment of the insurance company after the user pays the medical expense.
On the basis of the above embodiment, when determining the information of the amount of money to be paid and/or the information of the amount of money to be borne by the user in the total medical expense consumed by the user according to the user visit information, the medical service items covered by the user and the remaining claim amount information, the processing module 43 is configured to:
and if the diagnosis item contained in the user diagnosis information belongs to the medical service item covered by the user, determining the information of the amount to be paid according to the remaining claim amount information or deducting the amount to be paid from the total medical expense consumed by the user this time to obtain the information of the amount to be borne by the user.
On the basis of the above embodiment, when the information of the amount of money to be paid and/or the information of the amount of money to be assumed by the user is sent to at least one of the terminal device of the medical institution, the terminal device of the user, and the terminal device of the insurance company according to the claim settlement route, the output module 44 is configured to:
if the claim settlement way is the first claim settlement way, sending the information of the amount of money to be paid and/or the information of the amount of money required to be borne by the user to the terminal equipment of the medical institution and/or the terminal equipment of the user;
and if the claim settlement way is a second claim settlement way, sending the information of the amount of money to be paid and/or the information of the amount of money to be borne by the user to the terminal equipment of the insurance company or simultaneously sending the information of the amount of money to be paid and the information of the amount of money to be borne by the user to the terminal equipment of the insurance company and the terminal equipment of the user.
On the basis of the above embodiment, the processing module 43 is further configured to:
and after the claim is finished, updating the remaining claim amount information in the database according to the information of the amount to be paid.
The medical insurance claim settlement information processing apparatus provided in the embodiment of the present invention may be specifically configured to execute the method embodiment provided in fig. 1, and specific functions are not described herein again.
The medical insurance claim settlement information processing device provided by the embodiment of the invention receives a medical expense claim settlement request uploaded by a terminal device of a medical institution through a first claim settlement way, or receives a medical expense claim settlement request uploaded by a terminal device of a user or a terminal device of an insurance company through a second claim settlement way, wherein the medical expense claim settlement request comprises user diagnosis information; acquiring the medical service items covered by the user and the remaining claim settlement amount information from a database according to the diagnosis information of the user; determining information of the amount of money to be paid and/or information of the amount of money required to be borne by the user in the total medical expense consumed by the user according to the information of the doctor of the user, the medical service items borne by the user and the information of the remaining amount of money to be paid; and sending the information of the amount to be paid and/or the information of the amount to be borne by the user to at least one of the terminal equipment of the medical institution, the terminal equipment of the user and the terminal equipment of the insurance company according to the way of the claim settlement. The method has the advantages that the method can facilitate the user to carry out the claim settlement of medical insurance by providing various claim settlement approaches, save the time of the user and improve the user experience; meanwhile, the time efficiency of processing the claim cases by the insurance company can be improved, the labor cost is saved, and the accurate claim settlement of the claim cases in various claim settlement ways is realized.
Fig. 5 is a schematic structural diagram of a medical insurance claim settlement information processing apparatus according to an embodiment of the present invention. The medical insurance claim information processing device provided by the embodiment of the present invention may execute the processing flow provided by the medical insurance claim information processing method embodiment, as shown in fig. 5, the medical insurance claim information processing device 50 includes a memory 51, a processor 52, a computer program and a communication interface 53; wherein the computer program is stored in the memory 51 and is configured to be executed by the processor 52 by the medical insurance claim information processing method described in the above embodiment.
The medical insurance claim information processing device of the embodiment shown in fig. 5 can be used for implementing the technical solution of the above method embodiment, and the implementation principle and technical effect are similar, and are not described herein again.
In addition, the present embodiment also provides a computer-readable storage medium on which a computer program is stored, the computer program being executed by a processor to implement the medical insurance claim information processing method described in the above embodiment.
In the embodiments provided in the present invention, it should be understood that the disclosed apparatus and method may be implemented in other ways. For example, the above-described apparatus embodiments are merely illustrative, and for example, the division of the units is only one logical division, and other divisions may be realized in practice, for example, a plurality of units or components may be combined or integrated into another system, or some features may be omitted, or not executed. In addition, the shown or discussed mutual coupling or direct coupling or communication connection may be an indirect coupling or communication connection through some interfaces, devices or units, and may be in an electrical, mechanical or other form.
The units described as separate parts may or may not be physically separate, and parts displayed as units may or may not be physical units, may be located in one place, or may be distributed on a plurality of network units. Some or all of the units can be selected according to actual needs to achieve the purpose of the solution of the embodiment.
In addition, functional units in the embodiments of the present invention may be integrated into one processing unit, or each unit may exist alone physically, or two or more units are integrated into one unit. The integrated unit can be realized in a form of hardware, or in a form of hardware plus a software functional unit.
The integrated unit implemented in the form of a software functional unit may be stored in a computer readable storage medium. The software functional unit is stored in a storage medium and includes several instructions to enable a computer device (which may be a personal computer, a server, or a network device) or a processor (processor) to execute some steps of the methods according to the embodiments of the present invention. And the aforementioned storage medium includes: various media capable of storing program codes, such as a usb disk, a removable hard disk, a Read-Only Memory (ROM), a Random Access Memory (RAM), a magnetic disk, or an optical disk.
It is obvious to those skilled in the art that, for convenience and simplicity of description, the foregoing division of the functional modules is merely used as an example, and in practical applications, the above function distribution may be performed by different functional modules according to needs, that is, the internal structure of the device is divided into different functional modules to perform all or part of the above described functions. For the specific working process of the device described above, reference may be made to the corresponding process in the foregoing method embodiment, which is not described herein again.
Finally, it should be noted that: the above embodiments are only used to illustrate the technical solution of the present invention, and not to limit the same; while the invention has been described in detail and with reference to the foregoing embodiments, it will be understood by those skilled in the art that: the technical solutions described in the foregoing embodiments may still be modified, or some or all of the technical features may be equivalently replaced; and the modifications or the substitutions do not make the essence of the corresponding technical solutions depart from the scope of the technical solutions of the embodiments of the present invention.
Claims (10)
1. A medical insurance claim settlement information processing method is applied to a medical insurance claim settlement system server, and the method comprises the following steps:
receiving a medical expense claim settlement request uploaded by a terminal device of a medical institution through a first claim settlement way, or receiving a medical expense claim settlement request uploaded by a terminal device of a user or a terminal device of an insurance company through a second claim settlement way, wherein the medical expense claim settlement request comprises the information of the doctor visit of the user;
acquiring the medical service items covered by the user and the remaining claim settlement amount information from a database according to the diagnosis information of the user;
determining information of the amount of money to be paid and/or information of the amount of money required to be borne by the user in the total medical expense consumed by the user according to the information of the doctor of the user, the medical service items borne by the user and the information of the remaining amount of money to be paid;
and sending the information of the amount to be paid and/or the information of the amount to be borne by the user to at least one of the terminal equipment of the medical institution, the terminal equipment of the user and the terminal equipment of the insurance company according to the way of the claim settlement.
2. The method of claim 1, wherein the first claim approach is a claim approach in which claims are made before the user pays a medical fee;
the receiving of the medical expense claim settlement request uploaded by the terminal device of the medical institution through the first claim settlement way includes:
receiving a medical expense claim settlement request uploaded by a terminal device of the medical institution before a user pays a medical expense.
3. The method of claim 2, wherein for the first claim approach, prior to the receiving a medical claim request uploaded by a terminal device of a medical institution prior to payment of a medical fee by a user, further comprising:
receiving a diagnosis appointment request sent by terminal equipment of a user;
and inquiring the medical service item underwritten by the user and/or the residual claim amount information from the database according to the request of the residual claim amount information of the visit pre-residual claim amount information, and sending the residual claim amount information, the medical service item underwritten by the user and/or the claim amount information which is paid by the residual claim amount information to the terminal equipment of the user.
4. The method of claim 1, wherein the second claim settlement approach is a claim settlement approach for a user to settle a medical fee;
the receiving of the medical expense claim settlement request uploaded by the terminal device of the user or the terminal device of the insurance company through the second claim settlement approach includes:
and receiving a medical expense settlement request uploaded by the terminal equipment of the user or the terminal equipment of the insurance company after the user pays the medical expense.
5. The method according to any one of claims 1 to 4, wherein the determining information of the amount to be paid out and/or the information of the amount to be charged by the user in the total medical expense consumed by the user according to the information of the visit of the user, the items of medical services covered by the user and the information of the amount to be paid out comprises:
and if the diagnosis item contained in the user diagnosis information belongs to the medical service item covered by the user, determining the information of the amount to be paid according to the remaining claim amount information or deducting the amount to be paid from the total medical expense consumed by the user this time to obtain the information of the amount to be borne by the user.
6. The method according to any one of claims 1 to 4, wherein the sending the information of the amount to be paid and/or the information of the amount to be assumed by the user to at least one of a terminal device of a medical institution, a terminal device of the user, and a terminal device of an insurance company according to a claim settlement route comprises:
if the claim settlement way is the first claim settlement way, sending the information of the amount of money to be paid and/or the information of the amount of money required to be borne by the user to the terminal equipment of the medical institution and/or the terminal equipment of the user;
and if the claim settlement way is a second claim settlement way, sending the information of the amount of money to be paid and/or the information of the amount of money to be borne by the user to the terminal equipment of the insurance company or simultaneously sending the information of the amount of money to be paid and the information of the amount of money to be borne by the user to the terminal equipment of the insurance company and the terminal equipment of the user.
7. The method according to any one of claims 1-4, further comprising:
and after the claim is finished, updating the remaining claim amount information in the database according to the information of the amount to be paid.
8. A medical insurance claim settlement information processing apparatus, comprising:
the receiving module is used for receiving a medical expense claim settlement request uploaded by terminal equipment of a medical institution through a first claim settlement way, or receiving a medical expense claim settlement request uploaded by terminal equipment of a user or terminal equipment of an insurance company through a second claim settlement way, wherein the medical expense claim settlement request comprises user diagnosis information;
the query module is used for acquiring the medical service items covered by the user and the residual claim settlement amount information from the database according to the diagnosis information of the user;
the processing module is used for determining information of the amount of money to be paid and/or information of the amount of money required to be borne by the user in the total medical expense consumed by the user according to the information of the patient visit of the user, the medical service items covered by the user and the information of the remaining amount of money to be paid;
and the output module is used for sending the information of the amount to be paid and/or the information of the amount required to be borne by the user to at least one of terminal equipment of a medical institution, the terminal equipment of the user and the terminal equipment of an insurance company according to a claim settlement way.
9. A medical insurance claim settlement information processing apparatus, characterized by comprising:
a memory;
a processor; and
a computer program;
wherein the computer program is stored in the memory and configured to be executed by the processor to implement the method of any one of claims 1-7.
10. A computer-readable storage medium, having stored thereon a computer program;
the computer program, when executed by a processor, implementing the method of any one of claims 1-7.
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| CN201911163818.4A CN110992191A (en) | 2019-11-25 | 2019-11-25 | Medical insurance claim settlement information processing method, device, equipment and storage medium |
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| CN201911163818.4A CN110992191A (en) | 2019-11-25 | 2019-11-25 | Medical insurance claim settlement information processing method, device, equipment and storage medium |
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| CN110992191A true CN110992191A (en) | 2020-04-10 |
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