JP6805327B2 - Claim Assistance System and Claim Assistance Method - Google Patents

Description

The present invention relates to an insurance claim support system and a claim support method.

Medical expenses in Japan are increasing year by year, and it is expected that the public insurance system will be reviewed in the future. Under such circumstances, individuals and groups are increasingly using private medical insurance to cover medical expenses that are not covered by public insurance.

On the other hand, it cannot be said that each policyholder of the above-mentioned medical insurance, etc. accurately grasps the contract contents of the insurance. Therefore, even if an incident corresponding to the reason for insurance claim payment occurs, the policyholder is not even aware that it is the trigger for the insurance claim payment claim, and the insurance claim payment omission can easily occur. Alternatively, even if the policyholder is aware of the contract details, there are cases in which various procedures such as contacting the insurance company are troublesome and he / she neglects to make a payment request on his / her own will.

Of course, insurance companies are also making efforts to eliminate omissions in insurance claims, but the occurrence of the above-mentioned incidents can be recognized by the policyholder's own declaration, and there are limits to countermeasures.

Therefore, as a conventional technique for dealing with such a problem, for example, a step of receiving medical record information including examinee information, medical institution information, and medical / treatment content information from a server of a health insurance association, and the received medical record information are The step shifts to the step of determining whether or not the medical insurance contract for the examinee is compatible, and the procedure for paying medical benefits based on the medical insurance contract when it is determined to be compatible in the above determination. A medical benefit payment service method (see Patent Document 1), which is characterized by this, has been proposed.

Japanese Unexamined Patent Publication No. 2005-100165

As the prior art shows, it is useful to proceed with payment procedures appropriately based on medical record information. However, there are various types of information other than medical record information that can determine whether or not to claim insurance claims. For example, medical expense notifications sent regularly from the health insurance association, data such as receipts and electronic medical records created at hospitals, or receipts received by policyholders or insureds at hospitals or pharmacies, etc. is there. Moreover, the details of these pieces of information and the presence or absence of predetermined items are often different between the pieces of information, and the timing of provision is also different.

Therefore, the information used for determining whether or not to make a payment request described above varies depending on the circumstances and circumstances of the contractors, or the information management policy of hospitals, health insurance associations, and the like. In addition, various types of information including the above-mentioned medical record information tend to be a huge amount of data for the insured as a whole.

Therefore, if information that can collect multiple pieces of information about one insured person's one-time consultation is collected for a huge number of people and provided to the payment request approval / disapproval logic as it is, it will be processed as a whole. The speed and accuracy will be greatly reduced, and the efficient and accurate payment request procedure itself may become difficult.

Therefore, an object of the present invention is to provide a technique capable of appropriately processing information from various channels and supporting efficient and accurate insurance claim payment.

The insurance claim support system of the present invention that solves the above problems includes a communication device that communicates with one or a plurality of predetermined devices on the network, a storage device that holds insurance contract information indicating the contract contents of insurance products, and a predetermined one. clinical information about the insured insurance, the store to a predetermined device receives and stores device than, for those predetermined attributes of said storage the clinical information, and the process of selecting a predetermined algorithm, the selected medical care information Based on the identification information of the examinee shown, it is possible to identify the insurance product for which the examinee is insured from the information of the insurance contract, and to claim the insurance claim based on the selected medical information. When a notification to that effect is sent to the terminal of the policyholder of the specified insurance product and a request for execution of a payment request is received from the terminal , the policyholder makes an insurance contract with the selected medical information. It is characterized by including a process of transmitting to an information processing device of a tied insurance company and a computing device for executing the process.

Further, the insurance claim support method of the present invention includes information processing including a communication device that communicates with one or a plurality of predetermined devices on the network, and a storage device that holds insurance contract information indicating the contract contents of insurance products. The system receives medical information about the insured person of the predetermined insurance from the predetermined device, stores it in the storage device, and selects the stored medical information having a predetermined attribute by a predetermined algorithm, and the selection. Based on the identification information of the examinee indicated by the medical information provided, the process of identifying the insurance product for which the examinee is insured from the information of the insurance contract, and the claim for insurance payment based on the selected medical information. When a process of sending a notification to the terminal of the policyholder of the specified insurance product and a request for execution of a payment request are received from the terminal, the selected medical information is sent to the policyholder. Is characterized in that it executes a process of transmitting to an information processing device of an insurance company with which an insurance contract is concluded.

According to the present invention, it is possible to appropriately process information from various channels to support efficient and accurate insurance claim payment.

It is a network block diagram including the insurance claim support system in this embodiment. It is a figure which shows the hardware configuration example of the insurance claim support system in this embodiment. It is a figure which shows the configuration example of the filtering master table in this embodiment. It is a figure which shows the structural example of the payment filter table in this embodiment. It is a figure which shows the structural example of the exclusion filter table in this embodiment. It is a figure which shows the configuration example of the user master table in this embodiment. It is a figure which shows the configuration example of the contract content master table in this embodiment. It is a figure which shows the structural example of the insured person master table in this embodiment. It is a figure which shows the structural example of the medical care history table in this embodiment. It is a figure which shows the flow example 1 of the insurance claim support method in this embodiment. It is a figure which shows the flow example 2 of the insurance claim support method in this embodiment. It is a figure which shows the flow example 3 of the insurance claim support method in this embodiment. It is a figure which shows the screen example 1 in this embodiment. It is a figure which shows the screen example 2 in this embodiment. It is a figure which shows the screen example 3 in this embodiment. It is a figure which shows the screen example 4 in this embodiment. It is a figure which shows the screen example 5 in this embodiment. It is a figure which shows the screen example 6 in this embodiment.

--- Network configuration ---
Hereinafter, embodiments of the present invention will be described in detail with reference to the drawings. FIG. 1 is a diagram showing an example of a network configuration including the insurance claim support system 100 of the present embodiment. The insurance claim support system 100 shown in FIG. 1 is a computer system for appropriately processing information from various channels to enable efficient and accurate support for insurance claim payment.

The insurance claim support system 100 is connected to the network 10 and is capable of data communication with the user terminal 200, the insurance company system 300, the health insurance system 400, and the hospital system 500.

Of these, the user terminal 200 is a terminal of a policyholder who has a contract for medical insurance of an insurance company (including various insurance concepts including death protection in the contract content). Specifically, the user terminal 200 can be assumed to be a smartphone, a tablet terminal having a communication function, a PC, or the like, but the user terminal 200 is not limited thereto.

Further, the insurance company system 300 is a system operated by the above-mentioned insurance company, and determines whether to approve the insurance claim for the medical information based on the medical information transmitted from the insurance claim support system 100 ( It is a device that returns the judgment result to the insurance claim support system 100 (including the concept of acquiring the judgment result by the person in charge). Specifically, as the insurance company system 300, a server device can be assumed, but the present invention is not limited to this.

Further, the health insurance system 400 is a system of the health insurance association to which the above-mentioned policyholders and insureds belong, and is a computer system that provides medical information such as a receipt to the insurance claim support system 100. Specifically, as the health insurance system 400, a server device can be assumed, but the present invention is not limited to this.

The hospital system 500 is a system of a medical institution where the insured receives medical treatment, and is a computer system that provides medical information such as a receipt and an electronic medical record to the insurance claim support system 100. Specifically, as the hospital system 500, a server device can be assumed, but the present invention is not limited to this.

--- Hardware configuration example ---
The hardware configuration of the insurance claim support system 100 is as follows. The insurance claim support system 100 stores a storage device 101 composed of an appropriate non-volatile storage element such as a hard disk drive, a memory 103 composed of a volatile storage element such as RAM, and a program 102 stored in the storage device 101. A user terminal 200, an insurance company system 300, a health insurance system 400, which is connected to a computer device 104 such as a CPU and a network 10 that performs general control of the system itself and performs various determinations, calculations, and control processes. It also includes a communication device 105 that handles communication processing with other devices such as the hospital system 500.

In addition to the program 202, the above-mentioned storage device 101 includes a filtering master table 125, a payment filter table 126, an exclusion filter table 127, a user master table 128, a contract content master table 129, an insured person master table 130, and the like. The medical treatment history table 131 is stored. Details of each of these tables will be described later.

--- Data structure example ---
Subsequently, the tables used by the insurance claim support system 100 of the present embodiment will be described. FIG. 3 shows an example of the filtering master table 125 in this embodiment. The filtering master table 125 is a table that defines a filtering method of medical information for each insurance product of each insurance company. This filtering method is a target to be transmitted from the medical information stored in the storage device 101 for a predetermined period to the insurance company system 300 in order to request the approval decision of the insurance claim payment claim. Corresponds to the method of selecting.

The data structure consists of data such as the insurance company that sells the insurance product, the product name / special contract name of the insurance product, and the filter method, using the insurance product ID that uniquely identifies the insurance product, that is, the insurance product as a key. A collection of records. Of these, as specific examples of the filter method, a whitelist method and a blacklist method are assumed.

The whitelist method is a method in which the insurance company collates the information on the reason for insurance payment specified for each insurance product and selects medical information including information on injury or illness or medical practice corresponding to the reason for payment of the insurance money. .. The detailed contents of this whitelist method are specified in the payment filter table 126 described later.

On the other hand, the blacklist method collates information on injuries or medical treatments that do not fall under the insurance claim payment reasons specified by the insurance company for each insurance product, and provides information on injuries or medical treatments that do not fall under the insurance claim payment reasons. This is a method of selecting medical information that is not included. The detailed contents of this blacklist method are specified in the exclusion filter table 127.

FIG. 4A is a diagram showing a configuration example of the payment filter table 126 in the present embodiment. The payment filter table 126 is a table that stores the reasons for payment of insurance claims for insurance products for which the above-mentioned whitelist method is defined.

The data structure is a collection of records consisting of data such as the insurance company that sells the insurance product, the product name / special contract name of the insurance product, and the reason for payment, using the insurance product ID that uniquely identifies the insurance product as a key. Is.

FIG. 4B is a diagram showing a configuration example of the exclusion filter table 127 according to the present embodiment. The exclusion filter table 127 is a table that stores the reasons for exemption from payment of insurance claims for insurance products for which the above-mentioned blacklist method is defined.

The data structure is a record consisting of data such as the insurance company that sells the insurance product, the product name / special contract name of the insurance product, and the reason for exclusion of payment, using the insurance product ID that uniquely identifies the insurance product as a key. It is an aggregate.

FIG. 5A is a diagram showing a configuration example of the user master table 128 in this embodiment. The user master table 128 is a table that stores information on policyholders. The data structure is a collection of records consisting of data such as a policyholder name and a securities number of the insurance product, using a policyholder ID that uniquely identifies the policyholder, that is, the policyholder of the insurance product, as a key. In addition, since one policyholder may have contracts for a plurality of insurance products, a plurality of securities numbers may be included in one record.

FIG. 5B is a diagram showing a configuration example of the contract content master table 129 in this embodiment. The contract content master table 129 is a table that stores the contract content corresponding to the securities number stored in the user master table 125 described above.

The data structure uses the securities number stored in the above-mentioned user master table 125 as a key, the insurance product ID of the corresponding insurance product, the insured person ID that uniquely identifies the insured person, and the beneficiary of the insurance money. , Is a collection of records consisting of data such as.

FIG. 5C is a diagram showing a configuration example of the insured person master table 130 in this embodiment. The insured person master table 130 is a table that stores information about the insured person whose ID is stored in the contract content master table 129 described above.

The data structure is a collection of records composed of data such as the name of the insured person and the health insurance card number, using the insured person ID stored in the above-mentioned contract content master table 129 as a key.

FIG. 6 is a diagram showing a configuration example of the medical care history table 131 according to the present embodiment. The medical care history table 131 is a table that stores medical care information transmitted from each channel such as the user terminal 200, the health insurance system 400, and the hospital system 500.

The data structure is based on the insured's health insurance card number, which includes medical information, as well as the name, the date and time when the insured received medical treatment, the detection category (type of channel that received medical information), and medical treatment. From data such as the name of the medical institution that was performed, the name of the injury or illness to be treated, the medical treatment category (outpatient / hospitalization), the amount of medical expenses paid at the counter, the out-of-insurance medical treatment flag, the undiagnosed flag, the filtering flag, and the duplicate deletion flag. It is a collection of records consisting of.

Of these, the non-insurance medical care flag is a flag given to medical care information related to non-insurance medical care among medical care information.

In addition, the unconfirmed diagnosis flag corresponds to a flag given to medical information related to unconfirmed diagnosis contents among medical information. The medical information to which the undiagnosed flag is attached is excluded from the transmission target to the insurance company system 300.

In addition, the filter processing flag stores information in all insurance products (contract content master table 129) specified in the contract content by the insured indicated by the medical treatment information among the medical information (records in the medical treatment history table). This is a flag given to a product for which the determination of whether or not to request payment (FIG. 7A: s111), which will be described later, has been completed.

On the other hand, the duplicate deletion flag is the same medical treatment opportunity (that is, medical treatment date and time, medical institution name, injury / illness name) of the same insured person (that is, the same health insurance card number) in the medical information (record of the medical treatment history table). , And the medical care category is the same), that is, when there are multiple medical care information, it is given to medical care information other than one medical care information selected according to a predetermined priority among the duplicated medical care information. To.

As an example of the above-mentioned priority, the order in which the detection category is "receipt"> "hospital direct" (electronic medical record data, etc.)> manual (manual input by the policyholder from the user terminal 200) can be assumed, but of course. Not limited to this.

--- Flow example ---
Hereinafter, the actual procedure of the insurance claim support method in the present embodiment will be described with reference to the figure. Various operations corresponding to the insurance claim support method described below are realized by a program read by the insurance claim support system 100 into the memory 103 and executed. Then, these programs are composed of codes for performing various operations described below.

FIG. 7A is a diagram showing a flow example 1 of the insurance claim support method in the present embodiment. First, the insurance claim support system 100 accepts registration of reasons for payment related to insurance products from an appropriate information processing device of an insurance company (hereinafter referred to as an insurance company system 300) such as an insurance company system 300 as a preliminary process (s100). ).

At the time of accepting registration of the reason for payment, as shown in the detailed flow of FIG. 7B, what kind of policy should the claim assistance system 100 filter the medical information of the insured of each insurance product, for example? An interface such as a screen for asking the insurance company about, is transmitted to, for example, the insurance company system 300 (s1001).

The interface described above is, for example, a screen asking the insurance company whether it is a whitelist method or a blacklist method. If the filtering method desired by the insurance company for medical information related to a certain insurance product is the whitelist method, the payment filter table 126 is required for the insurance product. On the other hand, when the filtering method desired by the insurance company for the medical information of a certain insurance product is the blacklist method, the exclusion filter table 127 is required for the insurance product.

The person in charge of the above-mentioned insurance company confirms the above-mentioned screen or the like on the insurance company system 300, and selects a filtering method to be applied to medical information related to each insurance product of the company. At this time, the insurance company system 300 acquires the selected value and returns it to the insurance claim support system 100.

The insurance claim support system 100 receives the value of the above-mentioned filtering method from the insurance company system 300 (s1002), generates a record associated with the insurance product and the insurance company, and displays the value in the filtering master table 125. Store (s1003).

Next, the insurance claim support system 100 acquires information regarding the filtering method indicated by the reply from the insurance company system 300 (s1004).

When the information regarding the filtering method obtained above indicates the white list method (s1005: w), the claim assistance system 100 accepts the registration of the reason for payment of the insurance claim to the insurance company system 300. The screen is transmitted and the payment reason data is received from the insurance company system 300 (s1006). The insurance claim support system 100 creates a record by associating the received payment reason data with the corresponding insurance product, and stores this in the payment filter table 126 (s1007).

On the other hand, when the information regarding the filtering method obtained above indicates the blacklist method (s1005: b), the claim assistance system 100 makes the insurance company system 300 eligible for insurance payment. The reason data such as the name of the injury or illness, that is, the registration acceptance screen of the exclusion reason data is transmitted, and the exclusion reason data is received from the insurance company system 300 (s1008). The insurance claim support system 100 generates a record by associating the received exclusion reason data with the corresponding insurance product, and stores this in the exclusion filter table 127 (s1009).

Here, the explanation returns to the main flow of FIG. 7A. Following step s100 described above, the insurance claim support system 100 accepts user registration from a user who wants to receive insurance claim payment support, that is, a policyholder (s101).

In this case, the policyholder downloads and installs a predetermined application from the insurance claim support system 100 to the user terminal 200 at the time of the above-mentioned user registration (of course, the present invention is not limited to this form). Policyholders will be required to enter information such as their name, contracted insurance company and insurance product, their securities number, insured name, and health insurance card number on the interface of this app. The application that has received the information input uploads the input information to the insurance claim support system 100 via the user terminal 200 and the network 10. Subsequently, the insurance claim support system 100 determines whether or not there is a problem such as a defect in the content of the user registration received in s101 (s102).

As a result of this determination, for example, an omission of input of a predetermined item is specified, or it is found (by inquiring to the insurance company system 300) that the securities number entered by the policyholder does not exist. In the case (s103: n), the insurance claim support system 100 notifies the user terminal 200 of the corresponding user that the user registration is not possible (s104), and temporarily ends the process.

On the other hand, when the problem is not identified as a result of the above determination (s103: y), the insurance claim support system 100 appropriately extracts the values of each item included in the contents of the user registration received in s101, and the user Each record of the master table 128, the contract content master table 129, and the insured master table 130 is generated and registered (s105).

After that, the claim assistance system 100 provides the medical information of the insured person of the policyholder who has made the above-mentioned user registration to the user terminal 200, the health insurance system 400, and the hospital system 500 corresponding to each channel. Received from at least one of them, and stores this in the medical care history table 131 of the storage device 101 (s106). There may be cases where the policyholder and the insured are the same, and cases where the policyholder and the insured are different.

The medical information acquired and registered here includes medical expense notifications delivered monthly from health insurance to each policyholder, data-linked receipts from health insurance or payment funds, electronic medical records and receipt computers data-linked from medical institutions, and so on. Another example is the receipt information that the insured obtained from the medical institution for each medical treatment opportunity.

Of the above-mentioned medical information, regarding the receipt information, there is a case where the policyholder who obtained the receipt received by the insured at the medical institution obtains the information manually input by operating the user terminal 200. , It can be assumed that both the case of acquiring the scanned data by appropriately using the camera function of the user terminal 200 and the OCR application and the like can be assumed.

In this way, the policyholder may wish to operate the user terminal 200 to register medical information in the claim assistance system 100. In that case, the claim assistance system 100 that has received the predetermined request from the user terminal 200 returns the input screens 1000 and 1010 illustrated in FIGS. 8A or 8B to the user terminal 200 of the policyholder.

The policyholder will input medical information on any of the input screens 1000 and 1010 while referring to the above-mentioned receipt issued by a medical institution such as a hospital. When the policyholder uses the input screen 1000, the above-mentioned receipt is photographed by the camera of the user terminal 200, and the medical information is read by an appropriate OCR application. As a result, the user terminal 200 acquires values such as the date and time of medical treatment and the name of the medical institution as medical information, and transmits the values to the insurance claim support system 100.

On the other hand, when the above-mentioned policyholder uses the input screen 1010, he / she manually inputs or selects medical information while referring to the above-mentioned receipt. As a result, the user terminal 200 acquires values such as a medical treatment date and time, a medical treatment classification, and an injury / illness name as medical treatment information, and transmits the values to the insurance claim support system 100.

In addition, among the above-mentioned medical care information, regarding the medical expense notification, there are cases where the medical expense notification can be obtained as electronic data by receiving data linkage from the health insurance system 400, and the policyholder who browses the contents of the medical expense notification operates the user terminal 200. It is possible to assume both cases where the manual input is acquired.

Further, when the medical information is a medical expense notification as described above, it does not include data on the name of injury or illness. Therefore, the claim assistance system 100 identifies the medical care information based on this medical expense notification, and provides a predetermined interface (screen 1020 in FIG. 8C) that accepts the input of the name of injury or illness regarding the medical care information to the user terminal of the policyholder. It sends to 200 and accepts information input of injury and illness name. In this case, the insurance claim support system 100 sets the received injury / illness name information in the injury / illness name column in the above-mentioned medical information.

On the other hand, among the above-mentioned medical information, the data of the receipt, the electronic medical record, and the receipt computer contains detailed information, and basically no measures for compensating for the insufficient data are required. However, with regard to the receipt, a predetermined treatment is required when the so-called "receipt disease name", "suspected disease name", or the like regarding an injury or illness whose diagnosis is uncertain is included.

In this case, the insurance claim support system 100 shall add the undiagnosed flag "1" to the relevant medical information. The medical information to which the undiagnosed flag is added can be excluded from the targets to be transmitted to the insurance company system 300 in s111, which will be described later, that is, the approval judgment of whether or not the insurance money can be paid can be excluded.

Subsequently, the insurance claim support system 100 performs a pre-filtering process for selecting the medical information having a predetermined attribute from the medical information stored in the medical history table 131 in step s106 (s107).

In this case, the insurance claim support system 100 performs this filtering process, as shown in the flow of FIG. 7C, among the records of the medical care history table 131, that is, the medical care information, the same insured person (person with the same health insurance card number). ) When there are multiple medical information related to the same medical treatment opportunity (medical treatment date and time, medical institution name, injury / illness name, medical examination classification are the same), one medical information from the plurality of medical information can be selected between different types of medical information. Is selected based on a predetermined priority (s1071).

As an example of specific priority, the value of "detection category" of medical information is "receipt"> "hospital direct" (electronic medical record data, etc.)> manual (manual input by the policyholder from the user terminal 200). The order can be assumed, but of course, it is not limited to this.

The insurance claim support system 100 assigns the duplicate deletion flag "1" to the medical information other than one medical information in the medical history table 131 selected in s1071, that is, the medical information not selected in s1071. (S1072).

Further, if the medical information related to the non-insurance medical treatment exists among the medical information selected in the above-mentioned s1071, the insurance claim support system 100 adds the non-insurance medical treatment flag "1" to the medical information (s1074).

Here, the description of the flow of FIG. 7A returns. The insurance claim support system 100 is a health insurance card from the medical information selected by the above-mentioned pre-filtering (s107), which is not given the duplicate deletion flag and is not given the undiagnosed flag. Each value of the number, the name of injury or illness, and the examination category is extracted (s108).

Next, the insurance claim support system 100 identifies the insured person ID by collating, for example, the health insurance card number with the insured person master table 130 among the values obtained in s108, and uses this insured person ID as a key. The insurance product ID is specified in the contract content master table 129 (s109). The insurance product ID that can be specified here is the insured person ID corresponding to the number of records specified in the "insured person ID" column of the contract content master table 129, and may be one or more. is there.

Further, the claim assistance system 100 uses the filtering master table 125 as a key to filter the insurance product by using a predetermined one (eg, the one specified first) among the one or a plurality of insurance product IDs specified in s109. (S110).

Subsequently, the insurance claim support system 100 acquires information on the reason for payment or the reason for exclusion from the payment filter table 126 or the exclusion filter table 127 based on the insurance product and the filter method specified in s110, and is applicable based on this. It is determined whether or not a payment claim (to the insurance company) can be made with respect to the medical information (s111). The insurance claim support system 100 executes each of the above-mentioned processes of s110 and s111 by the number of insurance product IDs identified in s109, that is, by the number of insurance contracts applied to the insured person (s112). : N → s110 → s112 → s112: y), a filter processing flag is set in the medical history table 131 for the medical information for which the processing of s110 and s111 has been executed for all of the insurance contracts.

On the other hand, when the payment filter table 126 is used, the insurance claim support system 100 in s111 collates each value obtained in s108 with respect to the relevant medical information with the information on the reason for payment regarding the corresponding insurance product in the payment filter table 126. , Determine whether or not it corresponds to the injury or illness or medical practice corresponding to the payment reason.

On the other hand, when the insurance claim support system 100 uses the exclusion filter table 127, each value obtained in s108 regarding the relevant medical information is collated with the information on the reason for exclusion regarding the applicable insurance product in the exclusion filter table 127, and the relevant medical information is collated. Judge whether the medical information corresponds to the reason for exclusion.

If, as a result of the above-mentioned determination in s111, it is found that the relevant medical information cannot be claimed for insurance claims (s113: n), the insurance claim support system 100 cannot claim the relevant medical claims. The rejection report indicating the above is returned to the user terminal 200 of the policyholder (s114), and the process is completed.

On the other hand, when it is found that the relevant medical information can be claimed for insurance claims (s113: y), the insurance claim support system 100 can claim the insurance claims for the relevant medical information and actually makes a claim. A notification asking whether or not (see screen 1030 in FIG. 9) is transmitted to the user terminal 200 of the policyholder (s115).

The insurance claim support system 100 sends the above-mentioned notification in s115 to at least one terminal of the insurance claim recipient or the insured person indicated by the record of the insurance contract in the contract content master table 129. The relevant notification may be sent.

After the above notification is transmitted, when the user terminal 200 receives a reply that the payment request does not need to be executed (s116: n), the insurance claim support system 100 ends the process. On the other hand, when the user terminal 200 receives a reply that the payment request is required (s116: y), the insurance claim support system 100 sells the insurance product by requesting the approval of the payment request including the medical information. It is transmitted to the insurance company system 300 of the insurance company (s117).

In the insurance company, with respect to the above-mentioned approval request received by the insurance company system 300, a predetermined person in charge or a predetermined business system executes a determination process to determine whether or not the insurance money can be paid. Further, this determination result is returned from the insurance company system 300 to the insurance claim support system 100.

In this case, the insurance claim support system 100 receives the determination result of approval / disapproval of the insurance claim payment claim based on the above-mentioned medical information from the insurance company system 300 (s118).

If this determination result indicates that the insurance claim cannot be paid (s119: n1), the claim assistance system 100 sends a rejection report (see screen 1040 of FIG. 10A) to the user terminal 200 of the policyholder. It is delivered (s120) and the process is terminated.

On the other hand, when the above-mentioned judgment result indicates that a separate confirmation procedure is required for insurance claim payment (s119: n2), the claim assistance system 100 notifies that this confirmation procedure is necessary. Is transmitted to the user terminal 200 of the relevant policyholder described above (s121), and the process is temporarily returned to S118.

On the other hand, when the above-mentioned determination result indicates that the insurance claim can be paid (s119: y), the claim assistance system 100 determines the result of the insurance claim payment being approved (see screen 1050 in FIG. 10B). It is transmitted to the user terminal 200 of the relevant policyholder (s122), and the process is terminated.

According to this embodiment, the policyholder does not need to make a declaration by the policyholder regarding the outpatient treatment / treatment of the insured person to be contracted, and proactively pays insurance claims and avoids receiving a loss. Is possible. Therefore, omission of insurance claims will be appropriately prevented. In addition, the troublesome procedure for requesting payment such as "sending a medical certificate and taking action by the policyholder to the insurance company" is simplified. On the other hand, in insurance companies, non-payment events of insurance claims are effectively reduced. This is expected to provide policyholders with a good customer experience and to increase corporate value accordingly. In addition, when making a payment request, the sales staff will have an opportunity to contact the customer (insurance policyholder).

That is, it is possible to appropriately process information from various channels and support efficient and accurate insurance claim payments.

The description herein reveals at least the following: That is, in the insurance claim support system of the present embodiment, the computing device sends a notification to the contractor's terminal that the insurance claim can be claimed based on the medical information of the selected predetermined attribute. When the payment request is received from the terminal, the medical information may be transmitted to the information processing device of the insurance company.

According to this, it becomes possible to proceed with the procedure for claiming insurance claims according to the intention of the policyholder to implement the insurance claims, and it is possible to accurately avoid claims for claiming insurance claims against the intention. As a result, information from various channels can be processed as appropriate to support more efficient and accurate insurance claims.

Further, in the insurance claim support system of the present embodiment, the calculation device identifies the insurance claim recipient or the insured person based on the content information of the insurance contract held in the storage device in advance when the notification is transmitted. However, the notification may be transmitted to at least one terminal of the policyholder, the insurance beneficiary, and the insured person.

According to this, not only the policyholder but also the target person such as the insured or the beneficiary of the insurance can confirm the necessity of the insurance claim. As a result, it is possible to more accurately avoid claims for insurance claims against the intentions of each of these target persons.

Further, in the insurance claim support system of the present embodiment, when the arithmetic unit selects the medical information of the predetermined attribute, the medical information regarding the same medical treatment opportunity of the same insured person among the stored medical information When there are a plurality of such medical information, one medical information may be selected from the plurality of medical information by a predetermined algorithm.

According to this, when medical information from various channels such as medical expense notification, electronic medical record, receipt, and manual input by the policyholder regarding the same medical treatment opportunity of one insured person is stored in a predetermined period. It is possible to avoid the situation where medical information is duplicated and transmitted to the insurance company.

Further, in the insurance claim support system of the present embodiment, when selecting the one medical information, the arithmetic unit is based on a predetermined priority among different types of medical information from the plurality of medical information. It may be that one medical information is selected.

According to this, among the medical information from various channels such as medical expense notification, electronic medical record, receipt, and manual input by the policyholder obtained for the same medical treatment opportunity of one insured person, for example, more It is possible to give priority to the receipt for which detailed medical information can be obtained, and to exclude other medical information from being transmitted to the insurance company. As a result, duplicate transmission of medical information to the insurance company can be avoided accurately and efficiently.

Further, in the insurance claim support system of the present embodiment, when the computing device selects the medical information of the predetermined attribute, the stored medical information is paid by the insurance company for the insurance. It may be said that the medical information including the information on the injury or illness or the medical practice corresponding to the reason for payment of the insurance money is selected by collating with the information on the reason.

According to this, only medical information related to injuries and illnesses corresponding to the reason for payment of insurance money can be specified, and this can be transmitted to the insurance company to be subject to the approval judgment of whether or not the insurance money can be paid.

Further, in the insurance claim support system of the present embodiment, when the computing device selects the medical information of the predetermined attribute, the stored medical information is paid by the insurance company for the insurance. The medical information that does not include the information on the injury or illness or medical practice that does not correspond to the reason for payment of the insurance money may be selected by collating with the information on the injury or illness or medical practice that does not correspond to the reason.

According to this, medical information related to injuries and illnesses that do not correspond to the reason for payment of insurance money is excluded from a large number of medical information, and only the medical information after exclusion is sent to the insurance company to determine whether or not to pay insurance money. Can be the target of.

Further, in the insurance claim support system of the present embodiment, the arithmetic unit assigns a diagnosis unconfirmed flag to the received medical information when there is medical information related to the unconfirmed diagnosis content. Then, the process of excluding from the transmission target to the information processing apparatus of the insurance company may be further executed.

According to this, medical information including descriptions about injuries and illnesses whose diagnosis is uncertain, such as so-called "receipt disease name" and "suspected disease name" in the receipt, is specified and excluded from the transmission target to the insurance company, that is, insurance. It can be excluded from the approval judgment of whether or not to pay money.

Further, in the insurance claim support system of the present embodiment, when the medical information related to the non-insurance medical treatment exists among the received medical information, the arithmetic unit assigns the non-insurance medical treatment flag to the medical information. It may be transmitted to the information processing device of the insurance company.

According to this, among the medical information corresponding to the reason for payment of the insurance money, the information including the information on the non-insurance medical treatment can be identified and provided to the insurance company. In this case, the insurance company can easily determine whether or not to approve the insurance claim by confirming the special contract for out-of-insurance medical treatment and the provision of insurance claim payment for the insurance under contract by the policyholder.

Further, in the claim assistance system of the present embodiment, the arithmetic unit identifies the received medical information that does not include the injury / illness name, and provides a predetermined interface that accepts the input of the injury / illness name with respect to the medical information. , The information input of the injury / illness name is received by transmitting to the terminal of the contractor, the information of the received injury / illness name is added to the medical information, and then the selection process is performed by the predetermined algorithm. May be.

According to this, even if only medical information that does not include information on the name of injury or illness, such as medical expense notification, can be obtained, it can be dealt with, and it can be determined whether or not this medical information is to be transmitted to the insurance company. it can.

Further, in the insurance claim support system of the present embodiment, the computing device transmits the medical information to the information processing device of the insurance company, and then determines whether or not to approve the insurance claim based on the medical information. , The process of receiving from the information processing device and transmitting the received determination result to the contractor's terminal may be further executed.

According to this, the policyholders, etc. surely recognize the result of the approval decision regarding the medical information for which the insurance claim is requested, and by extension, uselessly implement it when considering the subsequent request for payment. It becomes easier to avoid the request. This leads to more efficient and accurate processing of insurance claims.

In the insurance claim support method of the present embodiment, the information processing system sends a notification to the contractor's terminal that the insurance claim can be claimed based on the medical information of the selected predetermined attribute. When it is transmitted and a payment request is requested from the terminal, the medical information may be transmitted to the information processing device of the insurance company.

In the insurance claim support method of the present embodiment, the information processing system identifies the insurance claim recipient or the insured person based on the content information of the insurance contract held in the storage device in advance when the notification is transmitted. , The notice may be transmitted to at least one of the contractor, the beneficiary, and the insured.

In the insurance claim support method of the present embodiment, when the information processing system selects the medical information of the predetermined attribute, among the stored medical information, the medical information regarding the same medical treatment opportunity of the same insured person is obtained. When there are a plurality of medical information, one medical information may be selected from the plurality of medical information by a predetermined algorithm.

In the insurance claim support method of the present embodiment, when the information processing system selects the one medical information, one of the plurality of medical information is selected based on a predetermined priority among different types of medical information. One medical information may be selected.

In the insurance claim support method of the present embodiment, when the information processing system selects the medical information of the predetermined attribute, the stored medical information is used as the reason for payment of the insurance money that the insurance company defines for the insurance. It is also possible to collate with the information of the above and select medical information including information on injury or illness or medical practice corresponding to the reason for payment of the insurance claim.

In the insurance claim support method of the present embodiment, when the information processing system selects the medical information of the predetermined attribute, the stored medical information is used as the reason for payment of the insurance money that the insurance company defines for the insurance. It is also possible to collate with the information of the injury or illness or medical practice that does not correspond to the above, and select the medical care information that does not include the information of the injury or illness or medical practice that does not correspond to the reason for payment of the insurance claim.

In the insurance claim support method of the present embodiment, when the information processing system has medical information related to unconfirmed diagnosis contents among the received medical information, the medical information is given a diagnosis unconfirmed flag. Then, the process of excluding from the transmission target to the information processing device of the insurance company may be further executed.

In the insurance claim support method of the present embodiment, when the information processing system has medical information related to non-insurance medical treatment among the medical information of the selected predetermined attribute, the medical information is given an out-of-insurance medical treatment flag. Then, it may be transmitted to the information processing device of the insurance company.

In the insurance claim support method of the present embodiment, the information processing system identifies the received medical information that does not include the injury / illness name, and provides a predetermined interface that accepts the input of the injury / illness name with respect to the medical information. The information input of the injury / illness name may be received by transmitting to the terminal of the contractor, the received information of the injury / illness name may be added to the medical information, and then the selection process may be performed by the predetermined algorithm.

In the insurance claim support method of the present embodiment, after the information processing system transmits the medical information to the information processing device of the insurance company, the determination result of approval / disapproval of the insurance claim based on the medical information is determined. The process of receiving from the information processing device and transmitting the received determination result to the contractor's terminal may be further executed.

10 Network 100 Claim Assistance System 101 Storage Device 102 Program 103 Memory 104 CPU (Arithmetic Logic Unit)
105 Communication device 125 Filtering master table 126 Payment filter table 127 Exclusion filter table 128 User master table 129 Contract details master table 130 Insured person master table 131 Medical care history table 200 User terminal 300 Insurance company system 400 Health insurance system 500 Hospital system

Claims (20)

A communication device that communicates with one or more predetermined devices on the network,
A storage device that holds insurance contract information that shows the contract details of insurance products,
A process of receiving medical information about an insured person of a predetermined insurance from the predetermined device, storing it in a storage device, and selecting a predetermined attribute of the stored medical information by a predetermined algorithm, and the selected medical information. Based on the identification information of the examinee shown by, it is possible to identify the insurance product for which the examinee is insured from the information of the insurance contract, and to claim the insurance claim based on the selected medical information. When a process of sending a notification to that effect to the terminal of the policyholder of the specified insurance product and a request for execution of a payment request are received from the terminal , the policyholder provides the selected medical information to the insurance contract. The processing that sends to the information processing device of the insurance company that connects the insurance company, and the computing device that executes
An insurance claim support system characterized by including. The arithmetic unit
Upon transmission of the notification, the insurance beneficiary or the insured is identified based on the information of the insurance contract, and the notification is sent to at least one terminal of the policyholder, the insurance beneficiary, and the insured. Is to send,
The insurance claim support system according to claim 1, characterized in that. The arithmetic unit
When selecting the medical information of the predetermined attribute, if there is a plurality of medical information regarding the same medical opportunity of the same insured person among the stored medical information, one medical information is specified from the plurality of medical information. It is the one that is selected by the algorithm,
The insurance claim support system according to claim 1, characterized in that. The arithmetic unit
When selecting the one medical information, one medical information is selected from the plurality of medical information based on a predetermined priority among different types of medical information.
The insurance claim support system according to claim 3, characterized in that. The arithmetic unit
When selecting the medical care information of the predetermined attribute, the stored medical care information is collated with the information of the insurance claim payment reason specified by the insurance company regarding the insurance, and the injury or illness or medical treatment corresponding to the insurance claim payment reason is collated. It selects medical information including information on actions,
The insurance claim support system according to claim 1, characterized in that. The arithmetic unit
When selecting the medical information of the predetermined attribute, the stored medical information is collated with the information of injury or illness or medical practice that does not correspond to the insurance payment reason specified by the insurance company for the insurance, and the insurance payment is made. Select medical information that does not include information on injury or illness or medical practice that does not correspond to the reason.
The insurance claim support system according to claim 1, characterized in that. The arithmetic unit
When medical information related to unconfirmed diagnosis content exists among the received medical information, a process of adding a diagnosis unconfirmed flag to the medical information and excluding it from being transmitted to the information processing device of the insurance company. Is to further execute,
The insurance claim support system according to claim 1, characterized in that. The arithmetic unit
When medical information related to non-insurance medical treatment exists among the received medical information, the non-insurance medical treatment flag is added to the medical information and transmitted to the information processing device of the insurance company.
The insurance claim support system according to claim 1, characterized in that. The arithmetic unit
Among the received medical information, those that do not include the injury / illness name are identified, and a predetermined interface that accepts the input of the injury / illness name regarding the medical information is transmitted to the terminal of the contractor to accept the information input of the injury / illness name. The received information on the name of the injury or illness is added to the medical information, and then the selection process is performed by the predetermined algorithm.
The insurance claim support system according to claim 1, characterized in that. The arithmetic unit
After transmitting the medical information to the information processing device of the insurance company, the judgment result of approval / disapproval of the insurance claim based on the medical information is received from the information processing device, and the received judgment result is the contract. It further executes the process of sending to the terminal of the person.
The insurance claim support system according to claim 1, characterized in that. An information processing system including a communication device that communicates with one or a plurality of predetermined devices on a network and a storage device that holds insurance contract information indicating the contract contents of insurance products .
A process of receiving medical information about an insured person of a predetermined insurance from the predetermined device, storing it in a storage device, and selecting a predetermined attribute of the stored medical information by a predetermined algorithm, and the selected medical information. Based on the identification information of the examinee shown by, it is possible to identify the insurance product for which the examinee is insured from the information of the insurance contract, and to claim the insurance claim based on the selected medical information. When a process of sending a notification to that effect to the terminal of the policyholder of the specified insurance product and a request for execution of a payment request are received from the terminal , the policyholder provides the selected medical information to the insurance contract. And the process of sending to the information processing device of the insurance company that connects
A claim assistance method characterized by performing. The information processing system
Upon transmission of the notification, the insurance beneficiary or the insured is identified based on the information of the insurance contract, and the notification is sent to at least one terminal of the policyholder, the insurance beneficiary, and the insured. To send,
The insurance claim assistance method according to claim 11 , characterized in that. The information processing system
When selecting the medical information of the predetermined attribute, if there is a plurality of medical information regarding the same medical opportunity of the same insured person among the stored medical information, one medical information is specified from the plurality of medical information. Select by algorithm,
The insurance claim assistance method according to claim 11 , characterized in that. The information processing system
When selecting the one medical information, one medical information is selected from the plurality of medical information based on a predetermined priority among different types of medical information.
The insurance claim assistance method according to claim 13 , characterized in that. The information processing system
When selecting the medical care information of the predetermined attribute, the stored medical care information is collated with the information of the insurance claim payment reason specified by the insurance company regarding the insurance, and the injury or illness or medical treatment corresponding to the insurance claim payment reason is collated. Select medical information, including behavioral information,
The insurance claim assistance method according to claim 11 , characterized in that. The information processing system
When selecting the medical information of the predetermined attribute, the stored medical information is collated with the information of injury or illness or medical practice that does not correspond to the insurance payment reason specified by the insurance company for the insurance, and the insurance payment is made. Select medical information that does not include information on injury or illness or medical practice that does not correspond to the reason,
The insurance claim assistance method according to claim 11, characterized in that. The information processing system
When medical information related to unconfirmed diagnosis content exists among the received medical information, a process of adding a diagnosis unconfirmed flag to the medical information and excluding it from being transmitted to the information processing device of the insurance company. To execute further,
The insurance claim assistance method according to claim 11 , characterized in that. The information processing system
If medical information related to non-insurance medical care exists among the received medical care information, the non-insurance medical care flag is added to the medical care information and transmitted to the information processing device of the insurance company.
The insurance claim assistance method according to claim 11 , characterized in that. The information processing system
Among the received medical information, those that do not include the injury / illness name are identified, and a predetermined interface that accepts the input of the injury / illness name regarding the medical information is transmitted to the terminal of the contractor to accept the information input of the injury / illness name. After adding the received information on the name of the injury or illness to the medical information, the selection process is performed by the predetermined algorithm.
The insurance claim assistance method according to claim 11 , characterized in that. The information processing system
After transmitting the medical information to the information processing device of the insurance company, the judgment result of approval / disapproval of the insurance claim based on the medical information is received from the information processing device, and the received judgment result is the contract. Further execute the process of sending to the person's terminal,
The insurance claim assistance method according to claim 11 , characterized in that.