CN114511411A

CN114511411A - Insurance prefix claim settlement method and device, electronic equipment and storage medium

Info

Publication number: CN114511411A
Application number: CN202210094812.1A
Authority: CN
Inventors: 刘明杰
Original assignee: Hui Medical Insurance Guangzhou Information Technology Co ltd
Current assignee: Hui Medical Insurance Guangzhou Information Technology Co ltd
Priority date: 2022-01-26
Filing date: 2022-01-26
Publication date: 2022-05-17

Abstract

The application provides a method and a device for pre-claiming insurance claims, electronic equipment and a storage medium, and relates to the technical field of insurance claims. The insurance prefix claim settlement method comprises the following steps: acquiring a medical diagnosis book of a user to be claimed, wherein personal information of the user to be claimed is recorded in the medical diagnosis book; inquiring the insurance type and the claim settlement amount of the insurance purchased by the user to be claim settled according to the personal information; acquiring medical records of users to be claimed from a medical database, wherein the medical records are recorded with medical item details and medicine list details; and determining the claimable amount of the user to be claimed based on the claim and payment terms, the medical item details, the medicine list details and the claim settlement limit corresponding to the insurance type, so that the medical expense is deducted according to the claimable amount when the user to be claimed settles the expense. The insurance preposed claim settlement method, the insurance preposed claim settlement device, the electronic equipment and the storage medium can complete the calculation of the claim settlement amount and the payment of the claim settlement for the user to be claimed very conveniently and rapidly.

Description

Insurance prefix claim settlement method and device, electronic equipment and storage medium

Technical Field

The present application relates to the field of insurance claim settlement technologies, and in particular, to a method and an apparatus for pre-claim settlement of insurance, an electronic device, and a storage medium.

Background

The medical insurance is an insurance system established for compensating the economic loss of workers caused by the disease risk, and after medical expenses occur when the personnel participating in the insurance visit the doctor for the illness, a certain economic compensation can be given by an insurance institution.

At present, the conventional medical insurance claim settlement is usually performed in a manner that after a user submits an insurance claim application, insurance claim settlement personnel performs data review, filing, claim case settlement and the like on the claim application submitted by the user. However, in such a manner, it takes a long time period for operations such as data auditing, filing, settling of claim cases, and the like, and a user needs to wait for a long time to obtain the claim amount, which results in poor user experience, and for some users who have insufficient cash and need to pay medical expenses by insurance claim payment, such a claim payment manner brings great inconvenience to the user.

Therefore, how to provide an effective solution to timely complete insurance claims of medical expenses has become an urgent problem in the prior art.

Disclosure of Invention

In a first aspect, an embodiment of the present application provides an insurance pre-claim method, including:

acquiring a medical diagnosis book of a user to be claimed, wherein personal information of the user to be claimed is recorded in the medical diagnosis book;

inquiring the insurance type and the claim settlement amount of the insurance purchased by the user to be claim settled according to the personal information;

acquiring medical records of the user to be claimed from a medical database, wherein the medical records are recorded with medical item details and medicine list details;

and determining the claimable amount of the user to be claimed based on the claim payment terms, the medical item details, the medicine list details and the claim settlement amount corresponding to the insurance type, so that the medical expense deduction is carried out according to the claim settlement amount when the user to be claimed settles the expense.

In one possible design, after querying the insurance type and the claim amount of the insurance purchased by the user to be claimed according to the personal information, the method further comprises:

and determining the deposit payment allowance of the user to be settled based on the insurance type and the settlement allowance so as to carry out deposit deduction according to the deposit payment allowance when the user to be settled pays the deposit.

In a possible design, the querying the insurance type and the claim settlement amount of the insurance purchased by the user to be settled according to the personal information includes:

according to the personal information and the name of the merchant insurance selected by the user to be claimed, inquiring whether a personal merchant insurance matched with the personal information exists from a merchant insurance server corresponding to the name of the merchant insurance;

inquiring whether a personal social security matched with the personal information exists from a social security server according to the personal information;

determining the insurance type and the claim settlement amount of the insurance purchased by the user to be claimed based on the inquired insurance type and the claim settlement amount recorded in the target insurance matched with the personal information;

wherein the target insurance is a personal quotient insurance matched with the personal information and/or a personal social insurance matched with the personal information.

In one possible design, the obtaining of the medical diagnostic book of the user to be claimed includes:

and acquiring the medical diagnosis book uploaded by the user to be claimed or acquiring the medical diagnosis book of the user to be claimed from a medical database of a hospital according to the personal information input by the user to be claimed.

In one possible design, the medical diagnostic book uploaded by the user to claim is in a picture format, and the method further includes:

and extracting the personal information in the medical diagnosis book in the picture format through an image recognition algorithm.

In one possible design, the method further includes:

acquiring reimbursement proportions of all medicines in the medicine list detail from a local medicine reimbursement database;

the determining the claimable amount of the user to be claimed based on the claim payment terms, the medical item details, the medicine list details and the claim settlement amount corresponding to the insurance type comprises:

and determining the claimable amount of the user to be claimed based on the claim and payment terms corresponding to the insurance type, the medical item detail, the medicine list detail, the claim settlement amount and the reimbursement proportion of each medicine in the medicine list detail.

In one possible design, the medical record records hospital names, and the obtaining reimbursement proportions of the drugs in the drug list detail from the local drug reimbursement database includes:

determining the area to which the hospital for the patient to be claimed belongs according to the hospital name;

and acquiring the reimbursement proportion of each medicine in the detail of the medicine list from a local medicine reimbursement database corresponding to the region based on the region to which the claim-pending user visiting hospital belongs.

In a second aspect, an embodiment of the present application provides an insurance pre-claim device, including:

the system comprises a first acquisition unit, a second acquisition unit and a third acquisition unit, wherein the first acquisition unit is used for acquiring a medical diagnosis book of a user to be claimed, and the medical diagnosis book records personal information of the user to be claimed;

the query unit is used for querying the insurance type and the claim settlement amount of the insurance purchased by the user to be claim settled according to the personal information;

the second acquisition unit is used for acquiring the medical record of the user to be claimed from a medical database, and medical item details and medicine list details are recorded in the medical record;

and the determining unit is used for determining the claimable amount of the user to be claimed based on the claim payment terms, the medical item details, the medicine list details and the claim settlement limit corresponding to the insurance type, so that the medical expense deduction is carried out according to the claimable amount when the user to be claimed settles the expense.

In a third aspect, an embodiment of the present application provides an electronic device, including a processor, a communication interface, a memory, and a communication bus, where the processor, the communication interface, and the memory complete mutual communication through the bus;

a memory for storing a computer program;

the processor is used for executing the program stored in the memory and realizing the following processes:

and determining the claimable amount of the user to be claimed based on the claim payment terms, the medical item details, the medicine list details and the claim settlement amount corresponding to the insurance type, so that the medical expense deduction is carried out according to the claimable amount when the user to be claimed settles the expense.

In a fourth aspect, an embodiment of the present application provides a computer-readable storage medium, in which a computer program is stored, and when executed by a processor, the computer program implements the following procedures:

The above-mentioned at least one technical scheme that this application one or more embodiments adopted can reach following beneficial effect:

the method comprises the steps of inquiring the insurance type and the claim settlement amount of insurance purchased by a user to be claimed through personal information, obtaining the medical record of the user to be claimed from a medical database, and determining the claimable amount of the user to be claimed based on the claim payment terms corresponding to the insurance type, the medical item details recorded in the medical record, the medicine list details recorded in the medical record and the claim settlement amount so as to cancel the medical fee according to the claimable amount when the user to be claimed settles the fee. So, can be very convenient and fast the completion to treating the claim user's but the calculation of claim amount and the payment of claim settlement to can directly deduct whole or partial medical expenses through the claim amount of claim settlement when settling medical expenses, promote user experience, not enough and the urgent need insurance claim and pay for fee the user of medical expenses and given very big facility to the cash, also be favorable to the popularization of medical insurance simultaneously.

Drawings

The accompanying drawings, which are included to provide a further understanding of the disclosure and are incorporated in and constitute a part of this specification, illustrate embodiments of the disclosure and together with the description serve to explain the disclosure without limiting the disclosure in any way. In the drawings:

fig. 1 is a flowchart of an insurance pre-claim settlement method according to an embodiment of the present application.

Fig. 2 is a flowchart of an insurance pre-claim settlement method according to another embodiment of the present application.

Fig. 3 is a schematic structural diagram of an electronic device according to an embodiment of the present application.

Fig. 4 is a schematic structural diagram of an insurance pre-processing claim settlement apparatus according to an embodiment of the present application.

Detailed Description

In order to facilitate calculation of the claim amount and payment of a user to be claimed, the embodiment of the application provides an insurance pre-claim method, an insurance pre-claim device, electronic equipment and a storage medium.

The insurance pre-claiming method provided by the embodiment of the application can be applied to a server of a medical insurance service provider or a server of a third-party medical insurance service provider, and it can be understood that the execution subject does not constitute a limitation to the embodiment of the application.

The insurance pre-claim method provided by the embodiment of the application will be described in detail below.

As shown in fig. 1, the insurance pre-claim settlement method provided by the embodiment of the present application may include the following steps:

step S101, acquiring a medical diagnosis book of a user to be claimed.

And the medical diagnosis book records the personal information of the user to be claimed.

In this embodiment of the present application, the medical diagnostic book is issued by a hospital, and personal information for identifying a user to be claimed is recorded on the medical diagnostic book, where the personal information at least includes an identification number for uniquely identifying the user to be claimed, and may also include other information such as name, gender, and year and month of birth, and this embodiment of the present application is not particularly limited.

The medical diagnostic book may be in an electronic document or picture format, and may be uploaded to the server by the user to be claimed, or may be acquired by the server from a medical database of the hospital according to personal information entered by the user to be claimed, which is not specifically limited in the embodiment of the present application. For example, in one possible design, when applying for insurance claims, the user to be claimed may take a medical diagnosis through a mobile phone and upload the medical diagnosis in the form of a picture taken to the server.

If the medical diagnostic book is in a picture format, after the medical diagnostic book in the picture format is acquired, the personal information in the medical diagnostic book in the picture format is extracted through an image recognition algorithm.

Step S102, inquiring the insurance type and the claim settlement amount of the insurance purchased by the user to be claimed according to the personal information.

The medical insurance can be divided into commercial insurance (merchant insurance) and social medical insurance (social insurance), if the user to be claimed purchases the commercial insurance, the user to be claimed can also manually select the name of the merchant insurance purchased by the user to be claimed when applying for insurance claim, and at the moment, the server can inquire whether the personal merchant insurance matched with the personal information exists from the merchant insurance server corresponding to the name of the merchant insurance according to the personal information and the name of the merchant insurance selected by the user to be claimed.

For example, in one embodiment, if the merchant insurance name selected by the user to be claimed when applying for insurance claims is "XX life", the service may initiate a query request to the background server of XX life according to the user information and the merchant insurance name "XX life" to query whether there is an individual merchant insurance matching the personal information, i.e., to query whether the user to be claimed purchases personal commercial insurance of XX life.

Meanwhile, the server inquires whether a personal social security matched with the personal information exists from the social security server according to the personal information, namely, whether the user to be claimed purchases the personal social security.

It can be understood that if the user to be claimed does not manually select the name of the personal insurance product purchased by the user when applying for insurance claim, the user may not inquire whether the personal insurance product matched with the personal information exists from the personal insurance server, or all the personal insurance servers may be inquired whether the personal insurance product matched with the personal information exists.

And finally, determining the insurance type and the claim amount of the insurance purchased by the user to be claimed based on the inquired insurance type and the claim amount recorded in the target insurance matched with the personal information. Wherein, the target insurance is a personal quotient insurance matched with the personal information and/or a personal social insurance matched with the personal information.

For example, in one embodiment, only the personal social security matched with the personal information is queried from the social security server, the type of insurance recorded in the personal social security is "type a insurance", and the claim amount is 20 ten thousand, and then the type of insurance purchased by the user to be claimed is "type a insurance" in the social security, and the claim amount is 20 ten thousand.

And step S103, acquiring the medical record of the user to be claimed from the medical database, wherein the medical record records the medical item detail and the medicine list detail.

The medical database can be a background database used for recording medical records of users at a hospital side, and when the medical records of the users to be claimed are acquired from the medical database, the medical records of the users to be claimed can be acquired from the medical database by taking the personal information of the users to be claimed as query conditions.

In practical situations, there are many hospitals for users to see a doctor, so the medical diagnostic book can also record the name of the hospital in which the doctor visits, obtain the medical record of the user to be claimed from the medical database, and obtain the medical record of the user to be claimed from the medical database of the corresponding hospital by using the personal information and the name of the hospital of the user to be claimed as query conditions. Wherein, the medical record records the medical item detail and the medicine list detail.

And step S104, determining the claimable amount of the user to be claim based on the claim payment terms, the medical item details, the medicine list details and the claim settlement limit corresponding to the insurance type, so that the medical expense deduction is carried out according to the claimable amount when the user to be claim settles the expense.

The insurance clauses are recorded with medical items and medicine names which can be paid, and theoretical claim amount can be obtained by calculating according to the medical items and the medicine names which can be paid and recorded in the claim clauses corresponding to the insurance type, and the medical item details and the medicine list details recorded in the medical records according to a certain proportion or by calculating in full. If the calculated theoretical claim amount does not exceed the claim amount (i.e. the maximum claim amount) of the insurance purchased by the user to be claimed, the calculated theoretical claim amount can be used as the claimable amount of the user to be claimed. If the calculated theoretical claim amount exceeds the claim amount of the insurance purchased by the user to be claimed, the claim amount of the insurance purchased by the user to be claimed can be used as the claimable amount of the user to be claimed, and medical expense deduction is directly carried out according to the claimable amount when the user to be claimed settles the expense.

The reimbursement rates for the same drug may vary from region to region, for example 80% for drug a and 90% for drug B in region B, and 70% for drug a and 75% for drug B in region C. Therefore, considering that different areas have different reimbursement proportions for the same drug, when carrying out pre-insurance claim settlement, the method can also be used for determining the area to which the hospital to be treated belongs according to the hospital name recorded in the medical diagnostic book, then obtaining the reimbursement proportions of the drugs in the drug list detail from the local drug reimbursement database corresponding to the area based on the area to which the hospital to be treated belongs, and finally determining the reimburseable amount for the user to be treated based on the claim terms, the medical item detail, the drug list detail, the claim limit and the reimbursement proportions of the drugs in the drug list detail corresponding to the insurance type.

Please refer to fig. 2, which is a flowchart illustrating another method for pre-insurance claim settlement according to an embodiment of the present application, wherein the method comprises the following steps:

step S201, a medical diagnostic book of the user to be claim is acquired.

Step S202, inquiring the insurance type and the claim settlement amount of the insurance purchased by the user to be claimed according to the personal information.

Step S203, determining the deposit payment allowance of the user to be settled based on the insurance type and the settlement allowance, so that the user to be settled can carry out deposit deduction according to the deposit payment allowance when paying the deposit.

Step S204, acquiring medical records of the user to be claimed from the medical database, wherein the medical records are recorded with medical item details and medicine list details.

Step S205, determining the claimable amount for the user to be claim based on the claim and payment terms, the medical item details, the medicine list details, the claim settlement amount and the deposit payment amount corresponding to the insurance type, so that the user to be claim can deduct the medical expense according to the claimable amount when settling the expense.

In the embodiment of the application, if the user to be claimed carries out fee deduction according to the deposit payment limit when paying the deposit, the deduction fee when paying the deposit needs to be subtracted from the deduction fee when the user to be claimed settles the fee.

In summary, according to the method for pre-claiming insurance provided in the embodiment of the present application, the insurance type and the claim amount of the insurance purchased by the user to be claim are queried through the personal information, the medical record of the user to be claim is obtained from the medical database, and the claimable amount for the user to be claim is determined based on the claim and payment terms corresponding to the insurance type, the details of the medical items recorded in the medical record, the details of the drug list recorded in the medical record, and the claim amount, so that the user to be claim can deduct the medical expense according to the claimable amount when the user to be claim settles the expense. So, can be very convenient and fast the completion to treating the claim user's but the calculation of claim amount and the payment of claim settlement to can directly deduct whole or partial medical expenses through the claim amount of claim settlement when settling medical expenses, promote user experience, not enough and the urgent need insurance claim and pay for fee the user of medical expenses and given very big facility to the cash, also be favorable to the popularization of medical insurance simultaneously. Meanwhile, the deposit payment amount of the user to be settled can be determined based on the insurance type and the settlement amount, so that the user to be settled can carry out deposit deduction according to the deposit payment amount when paying deposit, and the condition that medical treatment cannot be carried out in time due to insufficient deposit is avoided. In addition, according to different regions, the reimbursement proportion of each medicine in the detail of the medicine list can be obtained from the local medicine reimbursement database corresponding to the region according to the region to which the hospital for the user to be reimbursed belongs, so that the claim amount of different regions can be accurately determined, and the requirement of insurance prepositive claim of different regions can be met.

Fig. 3 is a schematic structural diagram of an electronic device according to an embodiment of the present application. Referring to fig. 3, at a hardware level, the electronic device includes a processor, and optionally further includes an internal bus, a network interface, and a memory. The Memory may include a Memory, such as a Random-Access Memory (RAM), and may further include a non-volatile Memory, such as at least 1 disk Memory. Of course, the electronic device may also include hardware required for other services.

The processor, the network interface, and the memory may be connected to each other via an internal bus, which may be an ISA (Industry Standard Architecture) bus, a PCI (Peripheral Component Interconnect) bus, an EISA (Extended Industry Standard Architecture) bus, or the like. The bus may be divided into an address bus, a data bus, a control bus, etc. For ease of illustration, only one double-headed arrow is shown in FIG. 3, but this does not indicate only one bus or one type of bus.

And the memory is used for storing programs. In particular, the program may include program code comprising computer operating instructions. The memory may include both memory and non-volatile storage and provides instructions and data to the processor.

The processor reads the corresponding computer program from the nonvolatile memory into the memory and then runs the computer program to form the insurance pre-claim device on the logic level. The processor is used for executing the program stored in the memory and is specifically used for executing the following operations:

The method executed by the insurance pre-claim settlement apparatus disclosed in the embodiment of fig. 3 of this application can be applied to or implemented by a processor. The processor may be an integrated circuit chip having signal processing capabilities. In implementation, the steps of the above method may be performed by integrated logic circuits of hardware in a processor or instructions in the form of software. The Processor may be a general-purpose Processor, including a Central Processing Unit (CPU), a Network Processor (NP), and the like; but also Digital Signal Processors (DSPs), Application Specific Integrated Circuits (ASICs), Field Programmable Gate Arrays (FPGAs) or other Programmable logic devices, discrete Gate or transistor logic devices, discrete hardware components. The various methods, steps and logic blocks disclosed in one or more embodiments of the present application may be implemented or performed. A general purpose processor may be a microprocessor or the processor may be any conventional processor or the like. The steps of a method disclosed in connection with one or more embodiments of the present application may be embodied directly in a hardware decoding processor, or in a combination of hardware and software modules within a decoding processor. The software module may be located in ram, flash memory, rom, prom, or eprom, registers, etc. storage media as is well known in the art. The storage medium is located in a memory, and a processor reads information in the memory and combines hardware thereof to complete the steps of the method.

The electronic device may further execute the methods shown in fig. 1 and fig. 2, and implement the functions of the embodiment of the insurance claim declaration apparatus shown in fig. 3, which are not described herein again in this embodiment of the present application.

Of course, besides the software implementation, the electronic device of the present application does not exclude other implementations, such as a logic device or a combination of software and hardware, and the like, that is, the execution subject of the following processing flow is not limited to each logic unit, and may also be hardware or a logic device.

Embodiments of the present application also propose a computer-readable storage medium storing one or more programs, the one or more programs comprising instructions, which when executed by a portable electronic device comprising a plurality of application programs, enable the portable electronic device to perform the method of the embodiment shown in fig. 1 and 2, and in particular to perform the following operations:

inquiring the insurance type and the claim amount of the insurance purchased by the user to be claim according to the personal information;

Fig. 4 is a schematic structural diagram of an insurance pre-processing claim settlement apparatus provided in an embodiment of the present application. Referring to fig. 4, in one software implementation, the insurance pre-claim device includes:

the system comprises a first acquisition unit, a second acquisition unit and a third acquisition unit, wherein the first acquisition unit is used for acquiring a medical diagnosis book of a user to be claim, and the medical diagnosis book records personal information of the user to be claim;

the second acquisition unit is used for acquiring the medical record of the user to be claim from a medical database, and the medical record records the medical item detail and the medicine list detail;

In short, the above description is only a preferred embodiment of this document, and is not intended to limit the scope of protection of this document. Any modification, equivalent replacement, improvement, etc. made within the spirit and principle of this document shall be included in the protection scope of this document.

The systems, devices, modules or units illustrated in the above embodiments may be implemented by a computer chip or an entity, or by a product with certain functions. One typical implementation device is a computer. In particular, the computer may be, for example, a personal computer, a laptop computer, a cellular telephone, a camera phone, a smartphone, a personal digital assistant, a media player, a navigation device, an email device, a game console, a tablet computer, a wearable device, or a combination of any of these devices.

Computer-readable media, including both permanent and non-permanent, removable and non-removable media, may implement the information storage by any method or technology. The information may be computer readable instructions, data structures, modules of a program, or other data. Examples of computer storage media include, but are not limited to, phase change memory (PRAM), Static Random Access Memory (SRAM), Dynamic Random Access Memory (DRAM), other types of Random Access Memory (RAM), Read Only Memory (ROM), Electrically Erasable Programmable Read Only Memory (EEPROM), flash memory or other memory technology, compact disc read only memory (CD-ROM), Digital Versatile Discs (DVD) or other optical storage, magnetic cassettes, magnetic tape magnetic disk storage or other magnetic storage devices, or any other non-transmission medium that can be used to store information that can be accessed by a computing device. As defined herein, a computer readable medium does not include a transitory computer readable medium such as a modulated data signal and a carrier wave.

All the embodiments in this document are described in a progressive manner, and the same and similar parts among the embodiments can be referred to each other, and each embodiment focuses on the differences from the other embodiments. In particular, for the system embodiment, since it is substantially similar to the method embodiment, the description is simple, and for the relevant points, reference may be made to the partial description of the method embodiment.

Claims

1. An insurance pre-claim method, comprising:

2. The method as claimed in claim 1, wherein after querying the insurance type and the claim amount of the insurance purchased by the user to be claimed according to the personal information, the method further comprises:

3. The method as claimed in claim 1, wherein the querying the insurance type and the claim amount of the insurance purchased by the user to be claimed according to the personal information comprises:

4. The method of claim 1, wherein the obtaining of the medical diagnostic book of the user to claim comprises:

5. The method of claim 4, wherein the medical diagnostic uploaded by the user to claim is in a picture format, the method further comprising:

6. The method of claim 1, further comprising:

the determining an amount of claim payable for the user to be claimed based on the claim terms, the medical item details, the medicine list details and the claim amount corresponding to the insurance type includes:

7. The method of claim 6, wherein the medical record includes a hospital name, and the obtaining of reimbursement proportions for each drug in the drug list detail from a local drug reimbursement database comprises:

8. An insurance pre-claiming device, comprising:

9. An electronic device is characterized by comprising a processor, a communication interface, a memory and a communication bus, wherein the processor and the communication interface are used for realizing the communication between the processor and the memory through the bus;

a memory for storing a computer program;

10. A computer-readable storage medium, in which a computer program is stored, which computer program, when being executed by a processor, carries out the following procedure: