CN214225970U - Commercial insurance direct claim system - Google Patents
Commercial insurance direct claim system Download PDFInfo
- Publication number
- CN214225970U CN214225970U CN202120031511.5U CN202120031511U CN214225970U CN 214225970 U CN214225970 U CN 214225970U CN 202120031511 U CN202120031511 U CN 202120031511U CN 214225970 U CN214225970 U CN 214225970U
- Authority
- CN
- China
- Prior art keywords
- insurance
- direct
- module
- service platform
- settlement
- Prior art date
- Legal status (The legal status is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the status listed.)
- Active
Links
Images
Abstract
A commercial insurance direct claim system, characterized by: the system comprises a direct claim terminal and a business insurance service platform, wherein the direct claim terminal is in two-way communication connection with the business insurance service platform; the system comprises a direct claim terminal, a business insurance service platform, a business insurance information system and a business insurance company, wherein the direct claim terminal comprises an input module, a display module, a processing module and a communication module, the business insurance service platform is in bidirectional communication connection with an HIS (health information system) of a medical institution through a data processing front-end processor arranged in the medical institution, and the business insurance service platform is in bidirectional communication connection with the insurance information system of the business insurance company through the communication module; the merchant insurance service platform comprises an authorization authentication unit, a medical data code matching unit and a fee settlement unit. The system effectively simplifies the claim settlement program and improves the claim settlement efficiency.
Description
Technical Field
The utility model relates to a commercial insurance directly claims the system, especially relate to data communication, medical data and commercial insurance data analysis and processing technology field.
Background
At present, the country promotes information sharing, strengthens the application of medical health big data, promotes the reform of medical payment mode, and better services medical insurance policy making and medical expense management. The existing commercial insurance claim settlement procedures, especially medical commercial insurance claim settlement, have four pain point problems: 1. for patients, the process is complicated, and time and labor are wasted. The patient need prepare complicated paper data, and financial affairs, technical staff need carry out complicated operation, and a large amount of property and manpower are consumed to whole process, and customer experience is poor, and the operation efficiency is low. 2. For hospitals, the data is incomplete and inaccurate. Limited by the operation capacity, hospital personnel cannot completely provide all medical data of the insured. Data loss becomes a common phenomenon in the industry, influences subsequent report extraction and data analysis, and influences patient compensation due to incomplete data. 3. The risk of fraud is enormous for insurance companies. By compiling false prescriptions and details, non-catalog medicines are changed into medicines in catalogues, medicines are sold, the medicine is hung in a bed and hospitalized, the medicine is filled with the medicine, false proofs are provided, and other fraudulent insurance fees are taken. 4. The data driving capability is insufficient for the data processing capability. Lack of complete and accurate background data seriously affects the identification of the hospital to the business insurance client, is not favorable for controlling the medical insurance fee by the hospital, and cannot provide a more optimal treatment scheme for the patient.
Disclosure of Invention
In view of this, the utility model provides a commercial insurance directly benefits system gets through the information isolated island between hospital mechanism, insurance agency, the patient through big data technology analysis, provides the settlement service of directly claiming the claim on the commercial insurance line to solve the problem that the claim flow is loaded down with trivial details, data driving force is not enough.
In order to solve the above problem, the technical scheme of the utility model realize as follows: a commercial insurance direct claim system, characterized by: the system comprises a direct claim terminal and a business insurance service platform, wherein the direct claim terminal is in two-way communication connection with the business insurance service platform;
the system comprises a direct claim terminal, a system management server and a system management server, wherein the direct claim terminal comprises an input module, a display module, a processing module and a communication module, the input module is used for receiving the information of treatment and application of insurance of a user, the display module is used for displaying the claim settlement process and settlement information, the processing module is used for processing claim settlement data, and the communication module is used for communicating with a merchant insurance service platform;
the business insurance service platform is in bidirectional communication connection with an HIS system of the medical institution through a data processing front-end processor arranged in the medical institution, and is in bidirectional communication connection with an insurance information system of a commercial insurance company through a communication module; the business insurance service platform works with the HIS system of the medical institution and the insurance information system of the business insurance company, and comprises an authorization authentication unit, a medical data code matching unit and a charge settlement unit.
Preferably, the communication module is a Modem, an ethernet communication module, a GPRS communication module, a CDMA communication module, a 4G or 5G communication module.
Preferably, the direct claim terminal is a portable terminal, a personal digital assistant, a desktop computer, an APP application, a wechat public number, or an applet.
Further, the authorization authentication unit is used for processing the identity and authorization information of the user transmitted by the direct claim terminal; the medical data code matching unit is used for converting the outpatient service or hospitalization information of the user acquired from the HIS system into standardized data; the fee settlement unit is used for processing and obtaining basic medical insurance expenditure fees, business insurance claim settlement fees and personal expenditure fees.
Further, the medical data code matching unit transmits the processed standardized data to an insurance information system of the commercial insurance company.
Further, the user inputs the hospitalizing and insurance application information through the direct settlement terminal before the hospitalizing settlement, and the commercial insurance settlement cost can be settled in real time after the hospitalizing settlement is finished.
Furthermore, the user can realize the quick settlement and claim settlement of the expenses of the commercial insurance claim settlement through the expense settlement unit of the direct claim terminal after the visit settlement.
Further, the business insurance service platform comprises a block chain storage module which comprises a plurality of storage nodes in communication connection and respectively stores medical data and business insurance data of users.
Further, the block chain storage module comprises an access authority distribution module, and according to the account authority of the accessor, the access authority of the storage node in the corresponding block chain is distributed to the accessor with different authorities.
Further, the visitors with different authorities access the medical data and the commercial insurance data on each storage node of the extraction block chain storage module through the public key, the private key and the hash value.
The utility model provides a direct claim system of commercial insurance includes directly claims terminal, trade insurance service platform, the trade insurance service platform with medical institution's HIS system with the insurance information system collaborative work of commercial insurance company, the trade insurance service platform is connected with medical institution's HIS system and commercial insurance company's insurance information system both-way communication, through medical data's standardization, each insurance company business process's standardization, utilizes block chain storage medical data and commercial insurance data, for the visitor's of different authorities distribution corresponds the access authority of the storage node in the block chain, decentralization guarantee data security.
Meanwhile, the system realizes the process of printing medical record data and diagnosis and treatment settlement documents to the insurance company for reimbursement in an off-line manner and transfers the process to the on-line full-automatic completion. The patient does not need to provide paper materials, does not need to run back and forth and fill in complicated documents, can realize immediate claims at the time of discharge or quick claims settlement after treatment, really realizes the online, paperless and mobile commercial insurance claims, and effectively solves the pain points of difficult claim settlement, slow reimbursement, frequent procedures and the like in the traditional online process.
Drawings
In order to more clearly illustrate the embodiments of the present invention or the technical solutions in the prior art, the drawings needed to be 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 inventive exercise.
Fig. 1 is an architecture diagram of a direct insurance system according to an embodiment of the present invention.
Fig. 2 is a schematic diagram of real-time settlement of commercial insurance according to an embodiment of the present invention.
Fig. 3 is a block diagram of a block chain storage device according to an embodiment of the present invention.
Detailed Description
The technical solution of the present invention is described in detail and completely with reference to the drawings and the specific embodiments.
The utility model provides a commercial insurance directly benefits system, including directly claiming a claim terminal, merchant and protecting service platform, directly claiming a claim terminal and merchant and protecting service platform both way communication and being connected, through medical data's standardization, each insurance company business process's standardization, with traditional off-line print case history data, diagnose settlement document to insurance company reimburse the process, shift to the full-automatic completion of on-line.
The patient can realize immediate claims at the time of discharge or quick claims after treatment through a small procedure of direct payment by the merchant insurance on line without providing paper materials, running back and forth and filling in complex documents, thereby really realizing the online, paperless and mobile aspects of commercial insurance claims and effectively solving the pain points of difficult claim settlement, slow reimbursement, frequent procedures and the like under the traditional line.
An architecture diagram of the commercial insurance direct claims system as described in figure 1.
The direct claim settlement terminal comprises an input module, a display module, a processing module and a communication module, wherein the input module is used for receiving the information of the doctor and the insurance application of a user, the display module is used for displaying the claim settlement process and the settlement information, the processing module is used for processing the claim settlement data, and the communication module is used for communicating with the merchant insurance service platform.
The merchant insurance service platform comprises an authorization authentication unit, a medical data code matching unit and a fee settlement unit. The authorization authentication unit is used for processing the identity and authorization information of the user transmitted by the direct claim terminal; the medical data code matching unit is used for converting the outpatient service or hospitalization information of the user acquired from the HIS system into standardized data; the fee settlement unit is used for processing and obtaining basic medical insurance expenditure fees, business insurance claim settlement fees and personal expenditure fees.
The business insurance service platform is in bidirectional communication connection with an HIS system of the medical institution through a data processing front-end processor arranged in the medical institution, and is in bidirectional communication connection with an insurance information system of a commercial insurance company through a communication module; the underwriting service platform works in cooperation with the HIS system of the medical institution and the insurance information system of the commercial insurance company.
Further, the medical data code matching unit transmits the processed standardized data to an insurance information system of the commercial insurance company. Specifically, four kinds of information, such as electronic medical record information, examination/inspection information, expense detail information, expense settlement information and the like, can be acquired, cleaned, mapped, and output to the insurance company after code matching. Meanwhile, the business processes and rules of the insurance companies are all not uniform, the hospital and each insurance company are complex in data butt joint, money making and account checking, the system integrates the requirements of all parties, unifies the processes, the rules and the data specifications, and meets the business requirements of the insurance companies by one-time butt joint with medical institutions.
Specifically, the communication module is a Modem, an ethernet communication module, a GPRS communication module, a CDMA communication module, or a 4G or 5G communication module.
Specifically, the direct claim terminal is a portable terminal, a personal digital assistant, a desktop computer, an APP application, a wechat public number, or an applet.
A schematic diagram of real-time settlement through a commercial insurance direct claims system is shown in fig. 2.
Before the settlement of the doctor, the user inputs the information of doctor seeking and insurance application through the direct settlement terminal, and the settlement of the doctor seeking can be finished, so that the settlement of the commercial insurance claim can be realized in real time.
Direct claim mode: the patient user initiates a data request at the hospital end or the insurance company end to support the on-line claim settlement application, and the real-time merchant insurance settlement is realized after the settlement of the normal outpatient service of the patient or during the hospitalization and the discharge settlement of the patient, so that the second claim of the merchant insurance settlement is realized.
The user can realize the quick settlement and claim settlement of the cost of the commercial insurance claim settlement through the cost settlement unit of the direct claim terminal after the visit settlement.
Direct claim mode: the patient user is firstly treated or hospitalized, after admission, application claim is initiated at a hospital end or an insurance company end, the insurance company collects the treatment information of the patient through a business insurance platform, and after discharge, the claim amount is audited and calculated, and the claim amount is paid to the patient user.
Taking a complete claim process of the user as an example:
the patient user initiates a data request at a hospital end or an insurance company end to support on-line claim settlement application, and the patient can select an 'insurance integrated service' module by using a direct claim terminal, wherein the direct claim terminal takes login APP or public numbers as an example, so as to complete real-name authentication.
The person who submits the case fills in the case information, and carries out the inquiry authorization confirmation of the electronic bill and the electronic medical record, the platform pushes the authorization information to the insured through APP or public number to carry out the confirmation (if the person who submits the case is the insured himself or has authorization in the past, the flow is skipped).
The merchant insurance service platform pushes the claim settlement report information to the insurance company in real time, and the insurance company carries out claim settlement operation according to the internal flow after receiving the report.
The insurance company pushes the medical electronic bill information and the electronic medical record information of the authorized user through the platform. And finishing the settlement payment process after the audit is passed (if the bill query fails, the audit process is performed under the wiring), and synchronizing the related information to the business insurance service platform.
The insurance company feeds back invoice claim settlement record information to the platform, and the platform feeds back the information to the HIS system of the hospital.
The insurance company pushes the relevant important nodes to the platform, and the user checks case updating information and historical case filing and claim settlement information through APP or public numbers.
Further, the system can also realize medical data sharing query. The insurance company can inquire the medical electronic bill information and the electronic medical record information of the authorized merchant insurance user through the commercial insurance service platform.
And the insurance company inquires corresponding electronic bill information and electronic medical record information according to the specific conditions.
And the business insurance service platform judges whether the user is authorized to the insurance company, if so, calls the bill query interface and the province health committee electronic medical record query interface, returns corresponding electronic bill information and electronic medical record information, if not, generates authorization to be dealt with, and after the user logs in through the APP or public number, performs authorization operation.
The insurance company receives the electronic bill and the electronic medical record information, checks the related data, carries out the claim settlement process, carries out the settlement payment after the claim settlement examination and verification is passed, and feeds back the claim settlement result information to the commercial insurance service platform, and the commercial insurance service platform informs the hospital HIS system after the verification information is correct.
After the insurance company uploads the claim information to the commercial insurance service platform, the platform and the bill center store the claim information completely for other insurance companies to inquire the corresponding information, and the bills are prevented from being repeatedly settled.
A block diagram of a block chain storage device as shown in figure 3.
And storing medical data and business insurance data by using the block chain, distributing access authorities of storage nodes in the corresponding block chain for visitors with different authorities, and centralizing to ensure data safety.
The business insurance service platform comprises a block chain storage module, a plurality of storage nodes and a business insurance data storage module, wherein the block chain storage module comprises a plurality of storage nodes which are in communication connection and respectively store the medical data and the business insurance data of users.
The block chain storage module comprises an access authority distribution module, and the access authority of the storage nodes in the corresponding block chain is distributed to the visitors with different authorities according to the account authority of the visitors.
And the visitors with different authorities access the medical data and the commercial insurance data on each storage node of the extraction block chain storage module through the public key, the private key and the hash value.
The platform data interface layer can adopt an SM2/SM3/SM4 encryption mode, and data sent out from the platform is encrypted and cannot be decrypted even if intercepted.
Through the technical means, the traditional process of printing medical record data and diagnosis and treatment settlement documents to the insurance company for reimbursement is realized, and the process is transferred to the on-line full-automatic completion. The patient can pay immediately when being discharged or settle the claim quickly after seeing a doctor on line without providing paper materials, online, paperless and mobile commercial insurance claim settlement is really realized, the pain points of difficult claim settlement, slow reimbursement, frequent procedures and the like under the traditional line are effectively solved, and the integrated service of hospitalizing, business insurance settlement and patient health guarantee is realized.
The above is only the partial embodiments of the present invention, it is right the protection scope of the present invention does not constitute a limitation, it can be extended to be applied to any intelligent device or system, all adopt the equivalent transformation or equivalent replacement and form the technical solution, all fall within the protection scope of the present invention.
Claims (4)
1. A commercial insurance direct claim system, characterized by: the system comprises a direct claim terminal and a business insurance service platform, wherein the direct claim terminal is in two-way communication connection with the business insurance service platform;
the system comprises a direct claim terminal, a system management server and a system management server, wherein the direct claim terminal comprises an input module, a display module, a processing module and a communication module, the input module is used for receiving the information of treatment and application of insurance of a user, the display module is used for displaying the claim settlement process and settlement information, the processing module is used for processing claim settlement data, and the communication module is used for communicating with a merchant insurance service platform;
the business insurance service platform is in bidirectional communication connection with an HIS system of the medical institution through a data processing front-end processor arranged in the medical institution, and is in bidirectional communication connection with an insurance information system of a commercial insurance company through a communication module; the merchant insurance service platform works in cooperation with the HIS system of the medical institution and the insurance information system of the commercial insurance company;
the merchant insurance service platform comprises an authorization authentication unit, a medical data code matching unit and a fee settlement unit.
2. The commercial insurance direct claims system of claim 1, wherein: the communication module is an Ethernet communication module, a GPRS communication module, a CDMA communication module, a 4G or 5G communication module.
3. The commercial insurance direct claims system of claim 1, wherein: the direct-payment terminal is a portable terminal, a personal digital assistant and a desktop computer.
4. The commercial insurance direct claims system of claim 1, wherein: the business insurance service platform comprises a block chain storage module, a plurality of storage nodes and a business insurance data storage module, wherein the block chain storage module comprises a plurality of storage nodes which are in communication connection and respectively store medical data and business insurance data of users.
Priority Applications (1)
| Application Number | Priority Date | Filing Date | Title |
|---|---|---|---|
| CN202120031511.5U CN214225970U (en) | 2021-01-07 | 2021-01-07 | Commercial insurance direct claim system |
Applications Claiming Priority (1)
| Application Number | Priority Date | Filing Date | Title |
|---|---|---|---|
| CN202120031511.5U CN214225970U (en) | 2021-01-07 | 2021-01-07 | Commercial insurance direct claim system |
Publications (1)
| Publication Number | Publication Date |
|---|---|
| CN214225970U true CN214225970U (en) | 2021-09-17 |
Family
ID=77709409
Family Applications (1)
| Application Number | Title | Priority Date | Filing Date |
|---|---|---|---|
| CN202120031511.5U Active CN214225970U (en) | 2021-01-07 | 2021-01-07 | Commercial insurance direct claim system |
Country Status (1)
| Country | Link |
|---|---|
| CN (1) | CN214225970U (en) |
Cited By (1)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN117635348A (en) * | 2023-11-29 | 2024-03-01 | 中国人寿保险股份有限公司山东省分公司 | Electronic bill insurance claim risk control method based on blockchain technology |
-
2021
- 2021-01-07 CN CN202120031511.5U patent/CN214225970U/en active Active
Cited By (1)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN117635348A (en) * | 2023-11-29 | 2024-03-01 | 中国人寿保险股份有限公司山东省分公司 | Electronic bill insurance claim risk control method based on blockchain technology |
Similar Documents
| Publication | Publication Date | Title |
|---|---|---|
| US6915266B1 (en) | Method and system for providing evaluation data from tracked, formatted administrative data of a service provider | |
| US4491725A (en) | Medical insurance verification and processing system | |
| US20070033070A1 (en) | System and method for collecting payments from service recipients | |
| KR100392331B1 (en) | System for managing medical insurance using information communication network and method therefore | |
| US6208973B1 (en) | Point of service third party financial management vehicle for the healthcare industry | |
| CN108154443A (en) | A kind of medical treatment medical insurance data processing equipment and method | |
| US20050033604A1 (en) | Method and apparatus for settling claims between health care providers and third party payers | |
| US20040006489A1 (en) | Benefits services payment and credit system | |
| WO2001004821A1 (en) | Method and apparatus for settling claims between health care providers and third party payers using a smart card id card | |
| CN102176263A (en) | Method related to self-service medicine taking from automatic medicine selling terminals in hospitals and automatic medicine taking system | |
| AU2008266173A1 (en) | System and method for delivering a procedure and controlling a procedure device | |
| KR20220073899A (en) | Method for dividing profit of medical service by sharing medical data employing blockchain | |
| CN214225970U (en) | Commercial insurance direct claim system | |
| CN110751992A (en) | Health card management platform | |
| CN111292841B (en) | Intelligent diagnosis system and diagnosis method based on accurate pricing | |
| CN214151779U (en) | Commercial insurance direct claim system | |
| CN111653329A (en) | Resident electronic health card external connection service platform system | |
| WO2000066367A1 (en) | A method, system and network for coordinating the communication of data for a health-related transaction | |
| CN214151778U (en) | Commercial insurance direct claim system | |
| JP2004126793A (en) | Medical bill payment system and medical bill payment method | |
| KR100452793B1 (en) | A certification system for medical insurance by using e-card | |
| CN113808761A (en) | Online prescription transfer method and system | |
| JP2002297911A (en) | Insurance money paying system, insurance money paying method and insurance money paying server | |
| JP2991685B2 (en) | Medical benefit processing device | |
| JP2002109042A (en) | Medical benefit procedure service method |
Legal Events
| Date | Code | Title | Description |
|---|---|---|---|
| GR01 | Patent grant | ||
| GR01 | Patent grant |