JP2002032474A - Method and system for reception qualification confirmation and payment settlement of public insurance system - Google Patents

Abstract

PROBLEM TO BE SOLVED: To provide a method for confirming the reception qualification of a public insurance system and a method and a system for payment settlement which can make electronic settlement speedy and secure. SOLUTION: This system has an affiliated store 1, a means 21 which inquires insurable information on a user of an insurant database 3 at a request for the affiliated store made by the user 2, a screen display means 22 which displays a request for service from the user and an answer from the database, a display screen means 23 which displays the identification of the user, whether or not the public insurance system is applicable, and a use limit amount when the system is applied, and a decision means 24 which decides the identification of the user, whether or not the public insurance system is applicable, and whether the request for service is within a usable range.

Description

DETAILED DESCRIPTION OF THE INVENTION

[0001]

BACKGROUND OF THE INVENTION 1. Field of the Invention The present invention relates to a method for confirming the eligibility of a public insurance system in Japan, a payment settlement method, and a system.

[0002]

2. Description of the Related Art When a user uses public insurance at a member store (hereinafter referred to as a nursing care service provider including a store or a facility), information such as excess or deficiency of payment, improper receipt, etc. is provided by public insurance. The survey was conducted based on the results of a survey by insurers.

[0003]

As described above, since the above is based on the result of the survey, there is a time difference as a judgment material when performing an immediate settlement such as an electronic settlement.

[0004] It is an object of the present invention to provide a method for confirming eligibility for payment of a public insurance system, a payment settlement method, and a system, which can quickly and surely perform electronic settlement.

[0005] The present invention does not leak personal information (including medical condition, degree of need for nursing care, etc.) unnecessarily and at the time of user's use of public insurance and at the time of payment (including electronic payment), the amount of payment is excessive or insufficient. , It is possible to make an immediate determination to prevent unauthorized receipt.

[0006]

SUMMARY OF THE INVENTION The present invention relates to a system in which a user (member) relates to a member store (a nursing care service provider, a medical institution, a public insurance applicable organization represented by dispensing, and a similar public assistance system). Institutions. The same shall apply hereinafter.) When using the public insurance system in Japan (and the similar public subsidy system; the same applies hereinafter), personal information of the user (information related to identity verification) is stored. The main purpose is to operate a public insurance system that stores information terminals or media that exist and information on users' public insurance use (including customer numbers, insured numbers, scheduled payments, performance management, etc.) ( Querying the insured database and collating the data from both to confirm the identity of the user required to determine the amount of payment to the merchant, public Applicability of the insurance system, available credit at the time of application, a decision such as the method of application (redemption payment, etc.) or public insurance Not applicable (full self-pay). As a result of the determination, the payment amount of the user is transmitted from the member store to a database mainly for financial settlement in which the user's name, card number (customer number), settlement limit, etc. are stored. At the same time, it inquires about the possibility of payment settlement.

In this case, since the information transmitted from the member store to the database mainly for financial settlement does not need to include information such as the condition of the user and the degree of need for nursing care, the condition of the user, Personal information such as the degree of care can be protected.

[0008] Further, information transmitted from a member store to a database mainly for financial settlement in which a user's name, an individual identification number (customer number), a settlement limit is stored, and the like is used as a usage history (accumulated. By using it as information, without including information on the user's medical condition, degree of nursing care, etc.
Benefits for users (including point back)
It can be performed.

[0009] Further, regarding the information transmitted from the member store to the database mainly for financial settlement, not only the user's payment burden but also the amount paid by the public insurance claim / payment organization to the member store, or By adding the user's payment burden rate or the public insurance claim / payment agency's payment burden rate and using it as usage history information,
It is possible to provide a privilege service that is more advantageous to the user without including information such as the degree of need for nursing care.

[0010] The service of the member store includes merchandise purchase and measures. Further, the insurer includes a proxy agency or a similar agency.

[0011]

Embodiments of the present invention will be described below with reference to the drawings.

FIG. 1 is a block diagram schematically showing an embodiment of the present invention. The qualification confirmation and payment settlement system 100 of the public insurance system is a member store (care service company).
1, users of the public insurance system (need caregivers, other families) 2
Database 3 that stores insured information (personal information) about, member store 1 and insured database 3
A network 4 for connecting the Internet, a database 5 of a financial institution that performs payment and settlement for the service received by the user 2, a privilege service database 6, a home care support company 7 that performs care plan transmission and monitoring,
A long-term care administration organization 8 having a public insurance claim / payment organization 9,
Elderly nursing home 11, nursing home 12, nursing home 1
3 and the like.

The member store 1 is provided with services such as home-visit nursing ST14, helper ST15, and bathing service 16, and the user 2 can receive services such as a day service 17 or a short stay 18.

[0015] Information search and record transmission are performed between the member store 1 and the network 4. Sent achievement is shared D
/ B, which is stored in the insured database 3
Various information from the nursing care institution 8 or the facility 10 is also stored in the database 3, and public information D / B19 and care D / B20.
Becomes For this reason, the information and the information of the care manager are transmitted and received.

[0015] From the insured person database side, an information terminal or medium (for example, a paper medium,
When the user receives a nursing care service, the user registers the usage status by collecting usage history data.

Inquiring means 21 for inquiring the insured person database 3 of insured information about the user 2 when the user 2 requests the service of the member store 1; Screen display means 22 for displaying a request for a service from the company and an answer from the insured person database 3, and a display screen for confirming the identity of the user 2, whether or not the public insurance system can be applied, and the usage limit at the time of application. Means 23 and determination means 24 for determining the identity of the user 2, applicability of the public insurance system, and determining whether a request for a service is within a usable range are provided.

Therefore, the insured person database that stores the insured information about the member store and the user, a network that connects the member store and the insured person database with a net, and payment settlement for the service received by the user Means for querying the insured person database for insured information about the user when the user requests the service of the affiliated store, and Screen display means for displaying the service request from the user and the answer from the insured person database, and display screen means for displaying the identity of the user, whether or not the public insurance system can be applied, and the usage limit at the time of application. And whether the user's identity, the application of the public insurance system and the request for services are within the available range, that is, the insurance coverage Eligibility confirmation and payment settlement system of the public insurance system and a judgment means for performing the Kano judgment is provided.

Further, when the user of the public insurance system requests a service of the member store, the member store queries the insured database for insured information on the user, A screen is displayed together with the service request from the user, and the user's identity is confirmed on the display screen, whether the public insurance system is applicable or not, and whether the service request is within the available amount at the time of application. A method of eligibility confirmation and payment settlement for the public insurance system to be provided is provided.

After the determination by the determination means, when a request for a service is made, the schedule of the payment burden is transmitted to the database of the financial institution storing the user's name, individual identification number, and settlement limit. (Not shown) for inquiring the payment settlement approval.

It has a privilege service database 6 for accumulating the payment burden transmitted to the database 5 of the financial institution as use history information, and provides privilege services to users.

The privilege service database 6 further stores the amount paid by the long-term care management organization 8 to the member store, the payment burden rate thereof, and the user payment burden rate.

FIG. 2 shows the relationship among the insured person database 3, network 4, member store 1, and financial institution database 5 in FIG. 1 in detail.

As shown in the figure, between the insured person and the shared D / B, reference / report of the payment result / plan / change data is made.

From the shared D / B, the insured person qualification, co-payment amount (rate), available amount, actual amount, payment method (redemption payment, etc.), implementation (benefit) schedule, each institution, facility, Customer (shared / individual) data of the business etc. is provided.

The following information is exchanged between the network 4 and the member store 1.

<Normal business> Report on the results of measures / services for users Confirmation of planned (benefit) schedules, available amount, etc.

<At the time of settlement> Determination of applicability of public insurance, available amount, payment method, etc. The following information is exchanged between the member store 1 and the database 5 of the financial institution.

<At the time of settlement> Settlement approval of user payment burden Report of user payment

FIG. 3 is a partially detailed block diagram of FIG. In this figure, the insurance operation sharing D / B is the insured person database 3, and the financial institution settlement D / B represents the database 5 of the financial institution.

As shown in the figure, an inquiry for determining the user's payment burden, and a settlement approval inquiry or report is made based on the inquiry result. By intervening humans,
Offline processing is also possible. This makes it possible to prevent leakage of personal information such as a user's medical condition or need for nursing care.

FIG. 4 is a block diagram showing an example of the processing. Performs identity verification 32 from the information terminal or the medium 31,
Refer to shared D / B 33, check benefits qualification (user-paid method) 34, actual (scheduled) check 35, available amount check 36
I do. After these confirmations, user payment burden determination 3
Perform Step 7.

FIG. 5 is a flow chart of a method for confirming the eligibility for receiving a public insurance system and a method for payment settlement. In this figure, the eligibility confirmation method and the payment settlement method are ST
It consists of EP1 to STEP10, and the contents of each are as follows.

S1: Registered member franchise (user store or use facility, etc.) S2: Request for actions, services, measures, sales, etc. related to the public insurance system at the member store (user store or use facility, etc.) S3: Check information such as name, individual identification number, insured number, customer number stored in the information terminal or medium S4: Name, individual identification number, insured number, customer number stored in the information terminal or medium And other information such as insured person qualification, insurance type, out-of-pocket amount (rate), available amount, actual results, payment method (redemption payment, etc.), implementation (benefit) schedule, customer of each institution, facility, business, etc. S5: Regarding payments made by an information terminal or a medium having a payment function, a determination is made by collating and judging information in a public insurance operation database including shared / individual) data and the like. Information S6: User payment amount information at the time of payment settlement performed by an information terminal or medium having a settlement function S7: Payment approval question of user payment amount at the time of payment settlement made by an information terminal or medium having a settlement function Matching S8: Information on payment made by cash S9: Information on user payment amount at the time of payment made by cash S10: Transmission of result information on user payment amount at the time of payment made by cash

[0034]

According to the present invention, personal information (including medical condition, degree of nursing care, etc.) is not unnecessarily leaked, and payment is made when the user uses public insurance and when making payment (including electronic payment). It is possible to make an immediate determination to prevent an excess or deficiency in the amount, unauthorized receipt, and the like.

[Brief description of the drawings]

FIG. 1 is a block diagram schematically showing an embodiment of the present invention.

FIG. 2 is a relationship diagram of a main configuration shown in FIG.

FIG. 3 is a partially detailed block diagram of FIG. 2;

FIG. 4 is a block diagram illustrating an example of a process.

FIG. 5 is a flow chart of a method for confirming eligibility for receiving a public insurance system and a method for payment settlement.

[Explanation of symbols]

1 ... Affiliated store, 2 ... User, 3 ... Insured person database,
4 Network, 5 Database of financial institutions, 6
Privilege service database, 8 ... Nursing care management organization, 10 ...
Facility, 21: inquiry means, 22: screen display means, 23
... display screen means, 24 ... judgment means, 100 ... eligibility confirmation and payment settlement system of public insurance system.

──────────────────────────────────────────────────続 き Continued on the front page (51) Int.Cl. ⁷ Identification symbol FI Theme coat ゛ (Reference) G06F 17/60 400 G06F 17/60 400 414 414

Claims (11)

[Claims] [Claim 1] Member stores (care service providers, medical institutions,
Public insurance organizations represented by dispensing, etc., and similar institutions related to the public subsidy system) provide services (including product purchases and measures) to the member stores from users (members) of the public insurance system. When a request is made, the insured person database is queried for the insured information about the user, the screen is displayed together with the request for the service from the user, and used on the display screen. A method for confirming the eligibility of a public insurance system and making a payment, characterized by confirming the identity of the person, determining whether or not the application of the public insurance system is applicable and, at the time of application, determining whether the service request is within the insurance coverage. 2. The method according to claim 1, wherein the request for the service at the time of application includes a payment rate or amount of a user, or a payment method, and a qualification confirmation and payment settlement method of a public insurance system. . 3. A system according to claim 1 or 2, wherein when a request for a service is made, a schedule of the payment burden is transmitted to a database of a financial institution storing a user's name, an individual identification number, and a settlement limit. A method for confirming eligibility of a public insurance system and paying for a payment, characterized in that the payment settlement approval is queried. 4. The method according to claim 3, wherein the payment burden transmitted to the database of the financial institution is stored in the privilege service database as usage history information. 5. The privilege service database according to claim 4, further comprising: an amount paid by the insurer or its agency (including an organization similar thereto) to the member store, a payment burden rate thereof, and a user payment burden rate. A method of confirming eligibility and payment settlement of the public insurance system, characterized by accumulation. 6. A member store, means for querying the insured person database for insured information on the user when the user requests the service of the member store, and the user Screen display means for displaying requests for services from the company and responses from the database, display screen means for confirming the identity of the user, whether or not the public insurance system can be applied, and the usage limit at the time of application, and use A means for confirming a person's identity, applicability of a public insurance system, and determining whether a request for a service is within the scope of insurance, and a qualification confirmation and payment settlement system for a public insurance system. 7. The financial institution according to claim 6, wherein when a request for a service is made after the judgment by said judging means, a database of a financial institution storing a user's name, an individual identification number, and a settlement limit is stored. A public insurance system eligibility confirmation and payment settlement system, wherein a payment schedule is communicated and payment settlement approval is inquired. 8. The public insurance system according to claim 7, wherein the payment burden transmitted to the database of the financial institution is stored in a privilege service database for accumulating as usage history information, and provided for a privilege service for the user. Eligibility confirmation and payment settlement system. 9. A member store, an insured person database for accumulating insured information about users, a network connecting the member store and the insured person database with a net, and payment settlement for services received by the user. Means for querying the insured person database for insured information about the user when the user requests the service of the affiliated store, and Screen display means for displaying the service request from the user and the answer from the insured person database, and display screen means for displaying the identity of the user, whether or not the public insurance system can be applied, and the usage limit at the time of application. And determination means for determining whether the user's identity, the application of the public insurance system, and the service request are within the insurance coverage. Eligibility confirmation and payment settlement system of public insurance system, characterized in that. 10. A system according to claim 9, wherein, after the determination by said determination means, when a request for a service is made, payment is made to a database of a financial institution storing a user's name, an individual identification number, and a settlement limit. A public insurance system for eligibility confirmation and payment settlement, characterized by having means for notifying a payment schedule and inquiring payment settlement approval. 11. The public insurance system according to claim 10, further comprising a privilege service database for accumulating, as usage history information, a payment burden transmitted to a database of a financial institution, and providing a privilege service to a user. Eligibility confirmation and payment settlement system.