JP2006039784A - Insurer system, qualification examination center system, medical service fees billing inspection system and computer program - Google Patents

Abstract

<P>PROBLEM TO BE SOLVED: To appropriately find out medical service fees billing after loss of qualification of an insurance card. <P>SOLUTION: When a person insured, or the like loses qualification of an insurance card, an insurer system 16 records the date of loss of qualification in a first insurance card information file 52. A qualification examination center system 14 obtains the first insurance card information file 52 and stores it as a second insurance card information file 40. In response to an inquiry of the qualification of the insurance card from a medical institution, the qualification examination center system 14 refers to the second insurance card information file 40, generates information of the insurance card and a history, such as the date of qualification examination, in a qualification examination history file 38, and stores it. In checking the content of the medical service fees billing, the insurer system 16 requests the qualification examination center system 14 to extract records, compares the date of qualification examination in the qualification examination history file 38 with the date of loss of qualification in the first insurance card information file 52, detects the medical service fees billing which includes billing after the loss of qualification of the insurance card, and outputs it in a loss of qualification file 48. <P>COPYRIGHT: (C)2006,JPO&NCIPI

Description

  The present invention relates to a system for inspecting a medical fee claim after loss of insurance card qualification, an insurer system, a qualification examination center system, and a program in the insurer system and the qualification examination center system.

  At insurance medical institutions (hospitals, clinics, etc., hereinafter simply referred to as “medical institutions”), at the first visit, from the insured (participants in the public medical insurance system) or dependents who are their families , Request the presentation of the insured card (hereinafter referred to as “insurance card”), and confirm the contents. If, as a result of the confirmation, it is determined that you are eligible for a health insurance card, a portion of the medical expenses will be charged directly to the insured or dependent, and other medical expenses will be charged to the insurer (city, social insurance agency, Requests to health insurance associations, mutual aid societies, etc.) via an examination and payment organization (an organization that mediates between medical institutions and insurers and reviews and pays for medical fees). If the insurance card is not presented or if it is determined that you do not qualify, the full amount of medical expenses will be charged directly to the insured or dependent.

  Since there is no information that the insurance card qualification has been lost on the insurance card, the medical institution cannot accurately determine whether or not the insurance card is qualified at the first visit, and the date of issuance of the insurance card, the insured person or the dependent It is judged whether there is a health insurance card qualification from alternative information such as date of birth and insurance card qualification acquisition date. In addition, at the time of re-examination, the insured person may receive medical examinations at multiple medical institutions or be used by dependents with a single insurance card information, so check whether the insurance card information has changed. Therefore, it is often requested to present an insurance card only at the beginning of the month, and the insurance card is not confirmed every time. Therefore, when an insurer is requested to pay medical expenses from a medical institution, it is necessary to confirm whether the insured or dependents actually have insurance card qualification at the time of medical treatment.

  If an insured or dependent has lost his / her insurance card qualification at the time of medical care, the insurer is not responsible for claiming the medical expenses and may request a refund or a reexamination request from the examination / payment institution. Is possible. In practice, however, an insurer often makes a payment to a medical institution once through an examination / payment institution, and confirms it strictly at a later date. If the insurer determines that he / she has lost his / her insurance card qualification, the medical expenses will be collected from the insured person or dependent, but the insurer is not able to make a judgment based solely on the information on the medical remuneration request, and the insurer has a heavy burden. It is often done.

  In some cases, a medical institution confirms the health insurance card qualification at the time of medical treatment, and only when the insurance card qualification is valid, the medical institution requests the medical examination fee from the examination payment institution. For example, in Patent Document 1, at the first visit, the validity of the insurance card is inquired from the card ID of the insurance card IC card to the use-prohibited insurance card IC card database. A technique is disclosed in which information is written and the validity check of a similar insurance card is performed from the insurance card information of the medical examination IC card at the time of re-acceptance.

  In Patent Document 2, a medical institution transmits a personal number obtained from insurance card information in a personal information card and a data update date to the insurance card qualification confirmation center, and the personal number received by the insurance card qualification confirmation center is a key information file. A technique is disclosed in which the medical institution transmits the latest insurance card information to the medical institution and the medical institution updates the personal information card if it is registered.

  Patent Document 3 discloses a recording unit in which the validity of an insurance card is recorded, a medium in which a symbol number assigned to one insurance card is recorded, a reading unit that reads out the symbol number, and a reading unit. A technique is disclosed that includes a confirmation unit that confirms the validity of a health insurance card to which a read symbol number is assigned based on a record of a recording unit.

Further, Patent Document 4 is provided with a qualification confirmation device having a database on insurance card qualification for each insured or dependent, and a medical institution connects to the qualification confirmation device and makes an inquiry about the insurance card qualification. The technology for confirming the insurance card qualification is disclosed.
JP 11-250140 A (page 2-4, FIG. 4-5) Japanese Patent Laid-Open No. 11-345263 (page 4-5, FIG. 7-8) JP 2003-167756 A (page 3-5, FIG. 2-4) JP 2003-208470 A (page 2-4, FIG. 11)

  However, even if such measures are taken, if the insured or dependent receives medical care before the information on the date of loss of insurance card qualification is reflected in the database related to the insurance card qualification of the qualification confirmation device, for example, the insurance card There is a problem that is deemed qualified. When an insured retires or a dependent takes a job, the insurer needs to undergo a procedure for loss of the insurance card qualification, but the insured has a certain grace period after the date of loss of the insurance card qualification Since it is only necessary to carry out procedures for loss of insurance card qualification via the office, a time lag occurs until the information on the date of loss of insurance card qualification is reflected in the insurance card information of the qualification confirmation device. When a medical institution makes a medical fee claim to an insurer via an examination / payment institution, in accordance with the rules for operation of the examination / payment institution, the medical institution is not a medical fee for each medical treatment, but an operation that requests a monthly medical fee. Yes. Therefore, if the date on which the insurance card qualification is lost is in the month, the insurer does not have details for each medical treatment, so the insurance fee qualification will be included in the monthly medical fee request from the examination and payment institution. There is a problem that it cannot be determined whether or not the medical fee claim is included. For example, as shown in FIG. 11, since the medical treatment on “medical day 2” is a medical treatment after the date of loss of qualification, the medical institution cannot charge the insurer. However, if the medical institution makes an inquiry before the date of loss of qualification is reflected in the database related to the insurance card qualification (for example, at the time of “medical treatment date 2”), it is determined that the qualification is made. In this case, the medical invoice request from the medical institution is the sum of the charges related to the two medical treatments of “medical day 1” and “medical day 2”, and the insurer is based on the medical fee claim information Therefore, it cannot be determined that the charge of “medical day 2” is included.

  An object of the present invention is to provide a system capable of appropriately finding a medical fee claim after loss of insurance card qualification as described above.

  In the present invention, when the insured or dependent loses the insurance card qualification, the insurer system registers the date of loss of qualification in the first insurance card information file. The qualification examination center system obtains the first insurance card information file from the insurer system, and saves it as the second insurance card information file. When the medical institution makes an inquiry about the insurance card qualification to the qualification examination center system having the function of confirming the insurance card qualification, the qualification examination center system refers to the second insurance card information file and performs the examination of the insurance card information and the qualification. Creates and saves the history such as the date in the examination history file.

  Further, the insurer system searches the examination history file described above when confirming the contents of the medical fee claim, and the qualification examination date of the examination history file and the qualification loss date of the first insurance card information file, Thus, the medical fee claim including the claim after loss of the insurance card qualification is detected and output to the loss of qualification file.

More specifically, the object of the present invention is to provide a first insurance card in which each record includes an item of insurance card key information that identifies an insured person or dependent and an item of the date of loss of qualification. An information file,
With reference to the first insurance card information file for a record of the medical fee claim information file including the medical institution identification code for identifying the medical institution, the medical institution identification code, the insurance card key information, and the claim insurance score, Determine whether the insured or dependent has already lost their qualification, and if they have already lost their qualification, enter the medical date, medical institution identification code and insurance card key information items. An extraction request file generation means for generating a record of an extraction request file including:
The information of the first insurance card information file is periodically acquired, the second insurance card information file is updated, and the second insurance card information file is referred to in response to the qualification inquiry of the medical institution system. In addition, the presence / absence of qualification is communicated to the medical institution system, and an examination history file including items of insurance card key information, medical institution identification code for qualification inquiry, qualification examination date, and qualification examination results An extraction file generated in a qualification examination center system configured to generate a record, wherein in the examination history file, the record of the extraction request file, insurance card key information, and medical In a record with a matching institution identification code, a qualified value is set as an item of the qualification review result, and the qualification review An extraction file including a record extracted when the date shown in the appendix and the medical treatment date coincide with each other is acquired, and the qualification examination date in the extraction file and the qualification loss date of the first insurance card information file are acquired. In the case of qualification, if the qualification has already been lost, the loss of qualification file including items of insurance card key information, medical institution identification code, qualification loss date, and qualification date This is achieved by an insurer system characterized by comprising a disqualification file generation means for generating a record of.

  According to the present invention, it is possible for an insurer to specify an insurance medical claim that is determined to have a qualification by an inquiry from a medical institution in spite of the loss of qualification at the qualification examination center. .

  The term “medical treatment date” refers to a time period based on the medical fee claim unit, and corresponds to “January **”, “February **” and the like.

In another embodiment of the present invention, the qualification review center system comprises:
Each record periodically obtains a first insurance card information file including an item of insurance card key information for identifying an insured person or a dependent person and an item of the date of loss of qualification. 2 is updated, and in response to the qualification inquiry of the medical institution system, referring to the second insurance card information file, the presence or absence of qualification is communicated to the medical institution system, and the insurance card An examination history file generating means for generating an examination history file record including key information items, medical institution identification codes for qualification inquiries, qualification examination dates, and qualification examination result items;
When obtaining a record of an extraction request file including items of medical treatment date, medical institution identification code and insurance card key information from an insurer, the record of the extraction request file in the examination history file, the insurance card key information, and A record with a matching medical institution identification code is found, and a qualification value is set as an item of the qualification examination result in the found record of the examination history file, and the date and medical treatment indicated in the qualification examination date item Extraction file generation means for generating an extraction file including the extracted record when the year and month match.

  This qualification examination center system generates an extraction file and gives it to the insurer system, so that the insurance medical treatment that has been determined to be qualified by the inquiry from the medical institution even after the qualification is lost. The claim can be specified by the insurer.

In addition, an object of the present invention is a medical fee claim inspection system including an insurer system and a qualification examination center system,
The insurer system is
A first insurance policy information file, each record including an item of insurance policy key information identifying an insured person or dependent, and an item of the date of loss of qualification;
With reference to the first insurance card information file for a record of the medical fee claim information file including the medical institution identification code for identifying the medical institution, the medical institution identification code, the insurance card key information, and the claim insurance score, Determine whether the insured or dependent has already lost their qualification, and if they have already lost their qualification, enter the medical date, medical institution identification code and insurance card key information items. An extraction request file generating means for generating a record of the extraction request file including,
The qualification examination center system
Periodically obtaining the first insurance policy information file, updating the second insurance policy information file, and referring to the second insurance policy information file in response to a qualification inquiry of a medical institution system In addition to communicating the presence or absence of qualification to the medical institution system, a record of an examination history file including items of insurance card key information, medical institution identification code related to qualification inquiry, qualification examination date, and qualification examination results An examination history file generation means to generate;
Upon obtaining the record of the extraction request file from the insurer, the record of the extraction request file is found in the examination history file and the record whose insurance card key information and medical institution identification code match, and the found examination is found. Extraction file that includes records extracted when a value with qualification is set as a qualification review result item in the record of the history file and the year and month indicated in the qualification date item match the medical treatment date And an extraction file generation means for generating
Furthermore, the insurer system has
When the qualification examination date in the extracted file is compared with the date of qualification loss in the first insurance card information file, and the qualification examination has already lost the qualification, the insurance card key information Also achieved by the medical fee claim inspection system characterized by the provision of a disqualification file generation means for generating a disqualification file record including items of medical institution identification code, disqualification date, and qualification review date Is done.

In a preferred embodiment, each time the extraction request file generation means of the insurer system generates a record of the extraction request file, the record is transmitted to the qualification examination center system via the network, and ,
The extracted file generation means of the qualification examination center system generates a record of the extracted file based on the received record, and transmits the record to the insurer system via the network.

Further, in another preferred embodiment, the extraction request file generation means of the insurer system transmits the extraction request file to the qualification examination center system via a network,
The extracted file generation means of the qualification examination center system transmits the extracted file to the insurer system via a network.

In yet another preferred embodiment, the extraction request file generation means of the insurer system stores the extraction request file in a portable storage medium, and
The extracted file generation means of the qualification examination center system generates a record of the extracted file based on the record of the extraction request file in the portable storage medium, and stores the extracted file in the portable storage medium.

In addition, an object of the present invention is to provide a first insurance card information file in which each record includes an item of insurance card key information for specifying an insured person or dependent and an item of the date of loss of qualification. A computer program readable by the computer for operating the computer provided as an insurer system, the computer comprising:
With reference to the first insurance card information file for a record of the medical fee claim information file including the medical institution identification code for identifying the medical institution, the medical institution identification code, the insurance card key information, and the claim insurance score, Determine whether the insured or dependent has already lost their qualification, and if they have already lost their qualification, enter the medical date, medical institution identification code and insurance card key information items. An extraction request file generation means for generating a record of an extraction request file including, and
The information of the first insurance card information file is periodically acquired, the second insurance card information file is updated, and the second insurance card information file is referred to in response to the qualification inquiry of the medical institution system. In addition, the presence / absence of loss of qualification is communicated to the medical institution system, and an examination history file including items of insurance card key information, medical institution identification code for qualification inquiry, qualification examination date, and qualification examination results An extraction file generated in a qualification examination center system configured to generate a record, wherein in the examination history file, the record of the extraction request file, insurance card key information, and medical In a record with a matching institution identification code, a qualified value is set as an item of the qualification review result, and the qualification review An extracted file including a record extracted when the date shown in the attached item matches the date of medical treatment is obtained, the date of qualification examination in the extracted file, and the qualification loss year of the first insurance card information file Qualification including items of insurance card key information, medical institution identification code, date of qualification loss, and qualification date This is achieved by a program characterized by functioning as a loss-of-qualification file generation means for generating a record of a lost file.

In another embodiment, a computer-readable computer program for causing a computer to operate as a qualification examination center system includes:
Each record periodically obtains a first insurance card information file including an item of insurance card key information for identifying an insured person or a dependent person and an item of the date of loss of qualification. 2 is updated, and in response to the qualification inquiry of the medical institution system, referring to the second insurance card information file, the presence or absence of qualification is communicated to the medical institution system, and the insurance card Examination history file generating means for generating a record of examination history file including items of key information, medical institution identification code for qualification inquiry, qualification examination date, and qualification examination result items, and
When obtaining a record of an extraction request file including items of medical treatment date, medical institution identification code and insurance card key information from an insurer, the record of the extraction request file in the examination history file, the insurance card key information, and A record with a matching medical institution identification code is found, and a qualification value is set as an item of the qualification examination result in the found record of the examination history file, and the date and medical treatment indicated in the qualification examination date item It functions as an extraction file generation means for generating an extraction file including an extracted record when the year and month match.

Another object of the present invention is to configure an insurer system in order to operate the insurer system and the qualification examination center system as a medical fee claim inspection system, and each record is insured or dependent. A first computer having a first insurance card information file including an item of insurance card key information for specifying the item and an item of the date of loss of qualification, and a second computer constituting the qualification examination center system A program readable by
For the record of the medical fee claim information file including items of medical institution date, medical institution identification code for specifying a medical institution, insurance card key information, and claim insurance score, the first computer has the first insurance card. Refer to the information file to determine whether the insured or dependent has already lost their qualification. If the qualification has already been lost, the date of medical treatment, medical institution identification code and It functions as an extraction request file generation means for generating an extraction request file record including an item of insurance card key information,
Said second computer;
Periodically obtaining the first insurance policy information file, updating the second insurance policy information file, and referring to the second insurance policy information file in response to a qualification inquiry of a medical institution system In addition to communicating the presence or absence of qualification to the medical institution system, a record of an examination history file including items of insurance card key information, medical institution identification code related to qualification inquiry, qualification examination date, and qualification examination results The examination history file generation means to be generated, and
Upon obtaining the record of the extraction request file from the insurer, the record of the extraction request file is found in the examination history file and the record whose insurance card key information and medical institution identification code match, and the found examination is found. Extraction file that includes records extracted when a value with qualification is set as a qualification review result item in the record of the history file and the year and month indicated in the qualification date item match the medical treatment date Function as an extraction file generation means for generating
The first computer;
When the qualification examination date in the extracted file is compared with the date of qualification loss in the first insurance card information file, and the qualification examination has already lost the qualification, the insurance card key information The invention is also achieved by a program that functions as a loss of qualification file generation means for generating a record of a qualification loss file including items of a medical institution identification code, a qualification loss date, and a qualification examination date.

In a preferred embodiment, when the first computer is caused to function as the extraction request file generating means, each time a record of the extraction request file is generated, the record is sent to the qualification examination center system. Operating the first computer to transmit via, and
When the second computer is caused to function as the extraction file generation means, a record of the extraction file is generated based on the received record, and the record is transmitted to the insurer system via the network. And operating the second computer.

In another preferred embodiment, when the first computer functions as the extraction request file generation means, the extraction request file is transmitted to the qualification examination center system via a network. Operating the first computer;
When the second computer is caused to function as the extracted file generation means, the second computer is operated so as to transmit the extracted file to the insurer system via a network.

In still another preferred embodiment, when the first computer is caused to function as the extraction request file generation means, the first computer is configured to store the extraction request file in a portable storage medium. Operate, and
When the second computer is caused to function as the extraction file generation means, a record of the extraction file is generated based on the record of the extraction request file in the portable storage medium, and the extraction file is stored in the portable storage The second computer is operated so as to be stored in a medium.

  According to the present invention, when the qualification examination center system confirms the insurance card qualification, the update of the insurance card qualification information is delayed, so that the insurance card qualification is actually lost but the insurance card qualification is present. Whether the insurer system includes a claim for medical examination after losing the insurance card qualification in the medical fee claim even if it is determined and a medical fee claim for the current medical treatment is made to the insurer Can be judged. As a result, the insurer can easily perform a refund request process or a reexamination request process to the examination / payment institution.

  Embodiments of the present invention will be described below with reference to the accompanying drawings. FIG. 1 is a block diagram showing an overall system configuration according to an embodiment of the present invention. As shown in FIG. 1, a medical institution system 12 and a qualification examination center system 14 are connected by a network 13, and a qualification examination center system 14 and an insurer system 16 are connected by a network 15. In FIG. 1, the network 13 and the network 15 are depicted as being different from each other. However, the present invention is not limited to such a configuration, and if the medical institution system 12 and the qualification examination center system 14 can communicate with each other. Good. The qualification examination center system 14 and the insurer system 16 do not necessarily have to be connected via a network.

  The medical institution system 12 is used by a medical institution. The insurer system 16 is used by an insurer. The qualification examination center system 14 has a function of confirming the validity of the insurance card qualification, and may be in an examination payment organization or a third party organization.

  The medical institution system 12 includes a medical institution server 22 and an input / output device 26. The medical institution server 22 includes a medical institution processing unit 24 that performs communication with a qualification examination processing unit 34 described later.

  The qualification examination center system 14 includes a qualification examination center server 32, an input / output device 36, an extraction file 37 stored in an external storage device, an examination history file 38, an extraction request file 39, and an insurance card information file 40. The qualification examination center server 32 includes a qualification examination processing unit 34 that performs qualification examination.

  The insurer system 16 includes an insurer server 42, an input / output device 46, a loss of qualification file 48 stored in an external storage device, an extraction file 50, an extraction request file 51, an insurance card information file 52 and a medical fee claim information file 53. Have. The insurer server 42 has an insurer processing unit 44 that detects a medical fee claim after loss of insurance card qualification.

  The qualification examination center system 14 receives the insurance card information file 52 stored in the external storage device of the insurer system 16 via the network 15 and stores it as the insurance card information file 40 in its own external storage device. Of course, the insurance card information file 52 may be a portable storage medium such as a magnetic tape, sent from the insurer, and stored in the external storage device of the qualification examination center system 14 as the insurance card information file 40.

  In addition, the qualification examination center system 14 obtains the change information of the insurance card information file 52 stored in the external storage device of the insurer system 16 periodically (for example, at a predetermined date and time every week). This is reflected in the insurance card information file 40 in the storage device. This change information may also be received via the network 15, or the information on the magnetic tape may be read using a magnetic tape or the like.

  FIG. 2 is a diagram showing a data structure of the insurance card information files 40 and 52. As shown in FIG. 2, the record of the insurance card information file includes, as items, an insurer number, an insured person symbol number, a name, a gender, and a date of birth (hereinafter, these items are referred to as “insurance card key information”. And the date of loss of qualification. The record of the insurance card information file is generated for each insured person or dependent. Further, as shown in FIG. 2, the date of loss of qualification in the insurance card information file stores the date of loss of qualification as a value. A record having a value in the date of loss of qualification is also stored for a certain period (for example, 6 months).

  In the medical institution, when the insured person or the dependent receives medical examination, the medical institution system 12 accesses the qualification examination center system 14 via the network 13 and requests the qualification examination of the insurance card. FIG. 3 is a flowchart illustrating an example of processing executed between the medical institution processing unit 24 and the qualification review processing unit 34.

  As shown in FIG. 3, the medical institution processing unit 24 receives the medical institution user ID and password input by operating the input / output device 26 by the person in charge of the medical institution via the network 13, and the qualification examination processing unit 34. To request connection (step 301). The qualification examination processing unit 34 compares the user ID and password registered in the external storage device in advance with the received user ID and password, and authenticates whether or not the request is valid (step 302). If the connection request is valid, the qualification review processing unit 34 transmits an input screen to the medical institution processing unit 24 (step 303). If it is determined that the request is not valid, the process is terminated without performing the connection.

  The medical institution processing unit 24 reads the insurance card key information input by the person in charge by operating the input / output device 26, displays it on the screen, and accepts confirmation of the person in charge (step 304). Is transmitted to the qualification examination processing unit 34 via the network 13 (step 305). The insurance card key information can be read by using an IC card or a magnetic card and having the card reader read these cards, or by a person in charge operating the keyboard and driving in. May be. The qualification inquiry message includes a medical institution identification code and insurance card key information. The medical institution identification code is a prefecture number and a medical institution code.

  The qualification examination processing unit 34 determines whether or not the value in the insurance policy key information included in the qualification inquiry message matches that registered in the insurance policy information file 40 of the external storage device, and the processing day. Is not later than the date of disqualification (step 306). This judgment corresponds to qualification examination. Next, the qualification examination processing unit 34 writes the qualification inquiry message, the qualification examination date, and the qualification examination result (“OK” or “NO”) in the examination history file 38 shown in FIG. 4 as an example (step 307). The examination result is transmitted to the medical institution processing unit 24 via the network 13 (step 308). Note that it is desirable to encrypt the record for transmission and reception. As shown in FIG. 4, in the examination history file 38, the record includes items of insurance card key information, medical institution identification code, qualification examination date, and qualification examination result.

  If the result of the qualification examination received by the medical institution processing unit 24 is “impossible”, the medical institution charges the insured person or dependent for the entire amount of medical expenses.

  FIG. 5 is a diagram showing an example of the data configuration of the medical fee claim information file 53. As shown in FIG. 5, the medical fee claim information file 53 includes, as items, a medical date, a medical institution identification code, an insurance card key information item, and a claim insurance score. FIG. 6 shows an extraction in which the insurer processing unit 44 designates an extraction condition based on the insurance card key information included in the medical fee claim information file 53 when the insurer receives the medical fee request information from the examination payment organization. FIG. 11 is a flowchart showing an example of processing for generating a request file 51, sending the request file to the qualification examination center online or offline, and the qualification examination processing unit 34 extracting records satisfying the extraction condition from the examination history file 38. . When the insurer receives the medical fee request information from the examination / payment institution in paper format, the insurer's person in charge inputs / outputs the medical date, medical institution identification code, and insurance card key information included in the medical fee request information in advance. It is input from the device 46 and stored in the external storage device as a medical fee claim information file 53. When the insurer processing unit 44 receives the medical fee request information record via the network or reads it from the electronic medium, the insurer processing unit 44 determines the medical year included in the medical fee request information record. The month, medical institution identification code, and insurance card key information are stored in the external storage device as a medical fee claim information file 53.

  In FIG. 6, the insurer processing unit 44 reads the date of medical treatment, the medical institution identification code, and the insurance card key information in the medical fee claim information file 53. Then, the health insurance card information file 52 is read based on the health insurance card key information (step 601), and it is checked whether or not the date of loss of qualification is set in the record specified by the insurance card key information (step 601). Step 602). If the value of the date of loss of qualification is set (“Yes” in step 602), the extraction condition including items of the medical date, medical institution identification code and insurance card key information shown in FIG. Are stored in the external storage device as the extraction request file 51 (step 603). These processes are repeated until the above-mentioned medical treatment date, medical institution identification code, and insurance card key information disappear (step 604).

  When the insurer system 16 and the qualification examination center system 14 are offline and are not connected via a network, the insurer processing unit 44 stores the extraction request file 51 in a portable storage medium such as a magnetic tape, and the insurer. The person in charge sends the portable storage medium to the qualification examination center, and requests extraction of a record that meets a predetermined condition from the examination history file 38. When the insurer system 16 and the qualification examination center system 14 are online connected as shown in FIG. 1, the insurer processing unit 44 qualifies the extraction request file 51 via the network 15. The information is transmitted to the processing unit 34 and requested to extract a record from the examination history file 38 (step 605).

  The predetermined condition is that, in the record in the examination history file 38, the item of the insurance card key information and the medical institution identification code in the record of the extraction request file 51 match, and the value of the qualification examination result is “OK”. In addition, the year and month indicated in the qualification examination date in the examination history file 38 and the medical treatment date and time in the record of the extraction request file 51 coincide with each other. The qualification examination processing unit 34 stores the received extraction request file 51 as an extraction request file 39 in the external storage device. Based on the extraction request file 39, a record that meets the predetermined condition is extracted from the examination history file 38 and stored in the external storage device as the extraction file 37 (step 606). The qualification review processing unit 34 stores the extracted file 37 in a portable storage medium when offline, and sends it to the insurer, or when online, via the network 15 to the insurer processing unit 44. Transmit (step 607).

  The insurer processing unit 44 reads a record stored in a portable storage medium when offline, stores it as an extraction file 50 of an external storage device, and records received via the network 15 when online, The extracted file 50 is stored in the storage device (step 608). The data structure of the extraction file 37 and the extraction file 50 is the same as that of the examination history file 38 (FIG. 4). Note that record transmission and record extraction requests and record reception via the network 15 are executed with user authentication. In this case, it is desirable to encrypt the record.

  FIG. 8 is a flowchart showing an example of qualification examination check processing after loss of insurance card qualification executed by the insurer processing unit 44 after the extracted file 50 is stored in the external storage device. First, the insurer processing unit 44 reads one record from the extracted file 50 (step 801).

  Next, the insurer processing unit 44 refers to the value of the insurance card key information item in the read record, searches the insurance card information file 52, and obtains a record that matches the value of the insurance card key information item. (Step 803). The insurer processing unit 44 compares the qualification examination date in the record of the extracted file 50 with the date of loss of qualification of the extracted insurance card information file 52 (step 804). Here, “qualification examination date ≧ date of qualification loss”, that is, if the date of qualification examination is after the date of qualification loss, it means that medical treatment has been received after the qualification loss, so it is determined that the qualification is lost (step In step 805, “Yes”), the insurer processing unit 44 writes the record information of the extraction file 50 as the record of the disqualification file 48 (step 806). As shown in FIG. 9, the record of the qualification loss file 48 includes, as items, an item of insurance card key information, a medical institution identification code, a qualification loss date, and a qualification examination date.

  The insurer processing unit 44 executes the above processing for all the records in the extraction file 50 (step 802).

  By executing such a process, the insurer separately provides medical invoice information on the date after the date of disqualification to the insured and / or medical institution based on the information in the record of the disqualification file 48. Can be inquired. As a result, it is possible to determine whether or not the medical fee request information includes a request when received after loss of the insurance card qualification. It can be easily performed.

  At present, the billing insurance points of the medical fee claim information are summed up for one month, and do not include detailed information for each medical day so as to grasp the day of medical care. Therefore, as shown in FIG. 11, when the medical institution performs the insurance card qualification examination process, it is answered that the qualification test result is “OK” because it is after the loss date of the insurance card qualification and before being reflected in the database. The medical treatment date is included in the medical remuneration claim information even though it is after the loss of insurance card qualification. This is because the result of the qualification examination is answered as “Yes”.

  According to the present invention, when an insurer receives medical fee request information of a person who has lost his / her insurance qualification, the insurance card information file 40 of the qualification examination center is updated after the date of loss of the insurance card qualification for the insured person. Check the number of days before the medical institution performed the insurance certificate qualification process, and if it is found that the medical institution performed the insurance certificate qualification process one day after the date of loss of the insurance card qualification The insurer can make an inquiry to the insured and / or the medical institution by some method.

  Next, another embodiment of the present invention will be described. In the first embodiment, the extraction request file 51 is generated based on the insurance card key information included in the record of the medical fee claim information file 53, and this is sent online or offline to the qualification examination center. ing. In the second embodiment, a record in the medical fee claim information file 53 is read, and the qualification examination processing unit 34 is requested to extract the record via the network 15 as necessary. FIG. 10 is a flowchart illustrating an example of processing executed between the qualification examination processing unit 34 and the insurer processing unit 44 according to the second embodiment.

  As shown in FIG. 10, the insurer processing unit 44 reads one record from the medical fee claim information file 53 (step 1001). Next, the insurer processing unit 44 finds the corresponding record in the insurance policy information file 52 based on the insurance policy key information of the read record (step 1003), and sets the value of the date of loss of qualification of the record. Is determined (step 1004).

  If no value is set in the item of the date of loss of qualification (“No” in step 1004), the process returns to step 1001 and proceeds to processing of the next record. If the value is set (“Yes” in step 1004), the insurer processing unit 44 sends an extraction condition message including the medical date, medical institution identification code, and insurance card key information to the network 15. Is sent to the qualification examination processing unit 34 (step 1005).

  When receiving the extraction condition message, the qualification examination processing unit 34 refers to the examination history file 38, and the value of the item in the record includes the condition (that is, medical date, medical institution identification code, insurance card). A record that matches (key information) and whose qualification examination result value is “OK” is extracted (step 1006). The extracted record is transmitted to the insurer processing unit 44 via the network 15 (step 1007).

  The insurer processing unit 44 refers to the received record and determines whether or not the date shown in the qualification examination date is after the date of loss of qualification in the record (step 1008). If “NO” is determined in the step 1008, the process returns to the step 1001 to proceed to processing of the next record. On the other hand, if “Yes” is determined in step 1008, a record including the insurance card key information item, the medical institution identification code, the date of loss of qualification, and the date of qualification review is generated. Write to the lost file 48 (step 1009). The insurer processing unit 44 executes the above-described processing for all records in the medical fee claim information file 53 (step 1002). In addition, when communicating between the insurer processing unit 44 and the qualification examination processing unit 34, it is desirable to communicate with authentication and to communicate by encrypting the record.

  The present invention is not limited to the above-described embodiment, and various modifications are possible within the scope of the invention described in the claims, and these are also included in the scope of the present invention. Needless to say.

FIG. 1 is a block diagram showing an overall system configuration according to an embodiment of the present invention. FIG. 2 is a diagram showing an example of the data structure of the insurance card information file. FIG. 3 is a flowchart illustrating an example of processing executed between the medical institution processing unit and the qualification review processing unit. FIG. 4 is a diagram showing an example of the data structure of the examination history file and the extracted file. FIG. 5 is a diagram illustrating an example of a data configuration of a medical fee claim information file. FIG. 6 is a flowchart showing an example of processing executed between the qualification examination processing unit and the insurer processing unit according to the present embodiment. FIG. 7 is a diagram illustrating an example of the data configuration of the extraction request file. FIG. 8 is a flowchart showing an example of qualification examination check processing after loss of insurance card qualification executed by the insurer processing unit after storing the extracted file in the external storage device. FIG. 9 is a diagram illustrating an example of the data structure of the disqualification file. FIG. 10 is a flowchart illustrating an example of processing executed between the qualification examination processing unit and the insurer processing unit according to the second embodiment. FIG. 11 is a diagram illustrating an example of a medical treatment date and a loss of qualification date.

Explanation of symbols

DESCRIPTION OF SYMBOLS 12 Medical institution system 13,15 Network 14 Qualification examination center system 16 Insurer system 22 Medical institution server 24 Medical institution processing part 32 Qualification examination center server 34 Qualification examination processing part 37 Extraction file 38 Examination history file 39 Extraction request file 40 Insurance card Information file 42 Insurer server 44 Insurer processing section 48 Loss of qualification file 50 Extraction file 51 Extraction request file 52 Insurance card information file 53 Medical fee request information file

Claims (12)

A first insurance policy information file, each record including an item of insurance policy key information identifying an insured person or dependent, and an item of the date of loss of qualification;
With reference to the first insurance card information file for a record of the medical fee claim information file including the medical institution identification code for identifying the medical institution, the medical institution identification code, the insurance card key information, and the claim insurance score, Determine whether the insured or dependent has already lost their qualification, and if they have already lost their qualification, enter the medical date, medical institution identification code and insurance card key information items. An extraction request file generation means for generating a record of an extraction request file including:
The information of the first insurance card information file is periodically acquired, the second insurance card information file is updated, and the second insurance card information file is referred to in response to the qualification inquiry of the medical institution system. In addition, the presence / absence of qualification is communicated to the medical institution system, and an examination history file including items of insurance card key information, medical institution identification code for qualification inquiry, qualification examination date, and qualification examination results An extraction file generated in a qualification examination center system configured to generate a record, wherein in the examination history file, the record of the extraction request file, insurance card key information, and medical In a record with a matching institution identification code, a qualified value is set as an item of the qualification review result, and the qualification review An extraction file including a record extracted when the date shown in the appendix and the medical treatment date coincide with each other is acquired, and the qualification examination date in the extraction file and the qualification loss date of the first insurance card information file are acquired. In the case of qualification, if the qualification has already been lost, the loss of qualification file including items of insurance card key information, medical institution identification code, qualification loss date, and qualification date An insurer system comprising: a disqualification file generation means for generating a record of Each record periodically obtains a first insurance card information file including an item of insurance card key information for identifying an insured person or a dependent person and an item of the date of loss of qualification. 2 is updated, and in response to the qualification inquiry of the medical institution system, referring to the second insurance card information file, the presence or absence of qualification is communicated to the medical institution system, and the insurance card An examination history file generating means for generating an examination history file record including key information items, medical institution identification codes for qualification inquiries, qualification examination dates, and qualification examination result items;
When obtaining a record of an extraction request file including items of medical treatment date, medical institution identification code and insurance card key information from an insurer, the record of the extraction request file in the examination history file, the insurance card key information, and A record with a matching medical institution identification code is found, and a qualification value is set as an item of the qualification examination result in the found record of the examination history file, and the date and medical treatment indicated in the qualification examination date item An qualification examination center system comprising: an extraction file generation means for generating an extraction file including an extracted record when the year and month match. A medical fee claim inspection system including an insurer system and a qualification examination center system,
The insurer system is
A first insurance policy information file, each record including an item of insurance policy key information identifying an insured person or dependent, and an item of the date of loss of qualification;
With reference to the first insurance card information file for a record of the medical fee claim information file including the medical institution identification code for identifying the medical institution, the medical institution identification code, the insurance card key information, and the claim insurance score, Determine whether the insured or dependent has already lost their qualification, and if they have already lost their qualification, enter the medical date, medical institution identification code and insurance card key information items. An extraction request file generating means for generating a record of the extraction request file including,
The qualification examination center system
Periodically obtaining the first insurance policy information file, updating the second insurance policy information file, and referring to the second insurance policy information file in response to a qualification inquiry of a medical institution system In addition to communicating the presence or absence of qualification to the medical institution system, a record of the examination history file including items of insurance card key information, medical institution identification code for qualification inquiry, qualification examination date, and qualification examination result items An examination history file generation means to generate;
Upon obtaining the record of the extraction request file from the insurer, the record of the extraction request file is found in the examination history file and the record whose insurance card key information and medical institution identification code match, and the found examination is found. Extraction file that includes records extracted when a value with qualification is set as a qualification review result item in the record of the history file and the year and month indicated in the qualification date item match the medical treatment date And an extraction file generation means for generating
Furthermore, the insurer system has
When the qualification examination date in the extracted file is compared with the date of qualification loss in the first insurance card information file, and the qualification examination has already lost the qualification, the insurance card key information A medical fee claim inspection system comprising: a qualification loss file generation means for generating a record of a qualification loss file including items of a medical institution identification code, a qualification loss date, and a qualification examination date. Each time the insurer system extraction request file generation means generates a record of the extraction request file, the record is transmitted to the qualification examination center system via the network, and
The extracted file generation means of the qualification examination center system generates a record of the extracted file based on the received record, and transmits the record to the insurer system via a network. The medical fee claim inspection system described in 1. The extraction request file generation means of the insurer system sends the extraction request file to the qualification examination center system via a network,
The medical remuneration claim inspection system according to claim 3, wherein the extracted file generating means of the qualification examination center system transmits the extracted file to the insurer system via a network. The extraction request file generation means of the insurer system stores the extraction request file in a portable storage medium, and
The extraction file generation means of the qualification examination center system generates a record of the extraction file based on the record of the extraction request file in the portable storage medium, and stores the extraction file in the portable storage medium. The medical fee reimbursement inspection system according to claim 3, A computer having a first insurance card information file in which each record includes an item of insurance card key information for specifying an insured person or a dependent person and an item of the date of loss of qualification, an insurer system A computer program readable by the computer for operating as a computer program,
With reference to the first insurance card information file for a record of the medical fee claim information file including the medical institution identification code for identifying the medical institution, the medical institution identification code, the insurance card key information, and the claim insurance score, Determine whether the insured or dependent has already lost their qualification, and if they have already lost their qualification, enter the medical date, medical institution identification code and insurance card key information items. An extraction request file generation means for generating a record of an extraction request file including, and
The information of the first insurance card information file is periodically acquired, the second insurance card information file is updated, and the second insurance card information file is referred to in response to the qualification inquiry of the medical institution system. In addition, the presence / absence of qualification is communicated to the medical institution system, and an examination history file including items of insurance card key information, medical institution identification code for qualification inquiry, qualification examination date, and qualification examination results An extraction file generated in a qualification examination center system configured to generate a record, wherein in the examination history file, the record of the extraction request file, insurance card key information, and medical In a record with a matching institution identification code, a qualified value is set as an item of the qualification review result, and the qualification review An extracted file including a record extracted when the date shown in the attached item matches the date of medical treatment is obtained, the date of qualification examination in the extracted file, and the qualification loss year of the first insurance card information file Qualification including items of insurance card key information, medical institution identification code, date of qualification loss, and qualification date A program that functions as a loss-of-qualification file generation means for generating a record of a lost file. A computer program readable by the computer for operating the computer as a qualification examination center system, the computer comprising:
Each record periodically obtains a first insurance card information file including an item of insurance card key information for identifying an insured person or a dependent person and an item of the date of loss of qualification. 2 is updated, and in response to the qualification inquiry of the medical institution system, referring to the second insurance card information file, the presence or absence of qualification is communicated to the medical institution system, and the insurance card Examination history file generating means for generating a record of examination history file including items of key information, medical institution identification code for qualification inquiry, qualification examination date, and qualification examination result items, and
When obtaining a record of an extraction request file including items of medical treatment date, medical institution identification code and insurance card key information from an insurer, the record of the extraction request file in the examination history file, the insurance card key information, and A record with a matching medical institution identification code is found, and a qualification value is set as an item of the qualification examination result in the found record of the examination history file, and the date and medical treatment indicated in the qualification examination date item A program that functions as an extraction file generation unit that generates an extraction file including an extracted record when the year and month match. In order for the insurer system and the qualification examination center system to operate as a medical fee claim inspection system, the insurer system is configured, and each record includes insurance card key information for identifying the insured person or the dependent. A program that can be read by a first computer having a first insurance card information file including an item and an item of the date of loss of qualification, and a second computer constituting the qualification examination center system ,
For the record of the medical fee claim information file including items of medical institution date, medical institution identification code for specifying a medical institution, insurance card key information, and claim insurance score, the first computer has the first insurance card. Refer to the information file to determine whether the insured or dependent has already lost their qualification. If the qualification has already been lost, the date of medical treatment, medical institution identification code and It functions as an extraction request file generation means for generating an extraction request file record including an item of insurance card key information,
Said second computer;
Periodically obtaining the first insurance policy information file, updating the second insurance policy information file, and referring to the second insurance policy information file in response to a qualification inquiry of a medical institution system In addition to communicating the presence or absence of qualification to the medical institution system, a record of an examination history file including items of insurance card key information, medical institution identification code related to qualification inquiry, qualification examination date, and qualification examination results The examination history file generation means to be generated, and
Upon obtaining the record of the extraction request file from the insurer, the record of the extraction request file is found in the examination history file and the record whose insurance card key information and medical institution identification code match, and the found examination is found. Extraction file that includes records extracted when a value with qualification is set as a qualification review result item in the record of the history file and the year and month indicated in the qualification date item match the medical treatment date Function as an extraction file generation means for generating
The first computer;
When the qualification examination date in the extracted file is compared with the date of qualification loss in the first insurance card information file, and the qualification examination has already lost the qualification, the insurance card key information , A program that functions as a loss of qualification file generation means for generating a record of a qualification loss file including items of medical institution identification code, qualification loss date, and qualification review date. When the first computer is caused to function as the extraction request file generation unit, each time a record of the extraction request file is generated, the record is transmitted to the qualification examination center system via the network. And operating the first computer, and
When the second computer is caused to function as the extraction file generation means, a record of the extraction file is generated based on the received record, and the record is transmitted to the insurer system via the network. The program according to claim 9, wherein the second computer is operated. When the first computer is caused to function as the extraction request file generation means, the first computer is operated so as to transmit the extraction request file to the qualification examination center system via a network,
When the second computer is caused to function as the extraction file generation means, the second computer is operated so as to transmit the extraction file to the insurer system via a network. The program according to claim 9. Operating the first computer to store the extraction request file in a portable storage medium when the first computer functions as the extraction request file generation unit; and
When the second computer is caused to function as the extraction file generation means, a record of the extraction file is generated based on the record of the extraction request file in the portable storage medium, and the extraction file is stored in the portable storage The program according to claim 9, wherein the second computer is operated so as to be stored in a medium.

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