KR20020081913A - A certification system and the method for medical insurance - Google Patents

Abstract

PURPOSE: A medical care insurance amount application certificating system and method is provided to enable a hospital to receive a certification number on application of an insurance amount for medical care to the NHIC(National Health Insurance Corporation) if a patient requests a medical treatment at the hospital with an electronic medical care insurance card, and to enable the NHIC to settle a medical treatment fee according to a review result of the HIRA(Health Insurance Review Agency) based on an application database of the NHIC. CONSTITUTION: The method comprises steps of a user subscribing for a medical insurance application certificating service at a credit card company and requesting an issue of an electronic medical insurance card(ST100), the credit card company asking the NHIC if the user can receive the certificating service(ST110), the credit card company issuing the electronic medical insurance card, and the NHIC storing the number of the card at a database(ST120), the user requesting a medical treatment at a hospital while offering the issued card(ST130), the hospital asking the NHIC if the user is registered as the certificating service member at the NHIC(ST140), the NHIC checking if the user is registered at the database(ST150), the hospital providing a medical treatment service to the user, receiving a medical treatment fee from the user, and requesting an application certificating number to the NHIC(ST160), the NHIC transmitting the application certificating number to the hospital, and the hospital storing the application certificating number with medical treatment specifications(ST170), the HIRA reviewing the medical treatment specifications and the medical treatment fee stored at the application database of the NHIC(ST180), and the HIRA transmitting a review result to the NHIC and paying the medical treatment fee the hospital according to the review result of the HIRA(ST180).

Description

Medical insurance claim certification system and method {A CERTIFICATION SYSTEM AND THE METHOD FOR MEDICAL INSURANCE}

The present invention relates to medical insurance claim authentication, in more detail, when a medical insurance card that has information about the medical insurance application is received at the hospital, the hospital receives a bill approval number from the health insurance management corporation The medical insurance claim certification system and method for recording patient medical records and request approval numbers in the database, and reviewing the information recorded in the database by the National Health Insurance Review and Evaluation Service will be.

The health insurance system is implemented in the country to reduce the burden on medical expenses such as medical expenses and medicines. When members borrow a certain amount of money and pay it to the Health Insurance Corporation, the Health Insurance Corporation manages the funds. It aims to reduce the burden on medical expenses by paying a certain portion of medical expenses to hospitals instead of subscribers. In addition, the health insurance system allows the members of the society to receive good medical services by varying the amount of money they pay according to the income and property of the subscriber. The purpose is to make it work.

In order to benefit many people, it is very important to manage the funds borrowed from the members, as well as to accurately pay for the medical bills billed by the hospital. Therefore, in order to accurately assess the medical bills charged by hospitals in the country, the health insurance review and evaluation unit shall be reviewed for the medical bills. However, since the data reviewed by the Health Insurance Review and Assessment Service are provided by the hospital, it can be easily manipulated in the hospital, which causes many difficulties in the screening.In addition, since most of the income of the Health Insurance Corporation is funded by members, Due to the burden of expense for the screening, it is difficult to conduct the screening correctly. Due to this problem, hospital bills are often overcharged, and many difficulties arise in the financial coverage of the medical insurance, and the burden on medical insurance increases due to the increase in the number of medical insurance. It is fading. In addition, doctors set high medical expenses due to unnecessary over medical treatment or unnecessary medicine, thereby increasing the burden on the member's medical insurance premiums.

Therefore, an object of the present invention is created to solve the above problems of the prior art, and provides a medical insurance card that can be processed electronically to the subscriber when the subscriber applies for and receive medical care at the hospital, the hospital In the case of receiving a claim number from the Health Insurance Corporation using the number of the medical insurance card, and recording the medical history and the claim number in the claim database, the reviewer evaluates the contents recorded in the claim database to authenticate the payment of medical expenses. The Review and Assessment Service can quickly and accurately review the hospital's claims, thereby reducing the burden on the Review and Evaluation, thereby faithfully managing the medical insurance finances, and ultimately reducing the burden on the number of members' health insurance. The doctor builds the process of treating a member in a database It is to provide a medical insurance claim certification system that can solve the problem of over-care.

Another object of the present invention is to provide a medical insurance claim authentication method that can solve the above problems.

In order to achieve the above object, the medical insurance claim authentication system according to the present invention is a medical insurance claim authentication system that manages the medical insurance finance by examining the medical insurance details requested by the hospital in the Health Insurance Review and Assessment Service, and joining the medical insurance. A medical insurance card with electronic processing held by a subscriber; A hospital server system having a means for reading a medical insurance card and a billing database for storing the medical treatment and the storage of the hospital; A health insurance corporation server system having means for holding information on the holder of the card for medical insurance; And it is characterized in that it is connected to the billing database consisting of a server system for the assessment and evaluation, so that the content recorded in the billing database can be audited,

In addition, in order to achieve the above another object, the medical insurance claim authentication method according to the present invention is a medical insurance claim authentication method for managing the medical insurance finances by examining the medical insurance details claimed by the hospital, Presenting a medical insurance card while the subscriber requests medical care at a hospital; Determining whether the person presenting the card is a legitimate person who can use the medical insurance certification service; Transmitting a request for approval number from the health insurance corporation to the hospital when the hospital requests the request for approval from the health insurance corporation; Storing the billing approval number in the health insurance corporation; Storing the medical history and the bill approval number of the subscriber in the billing database at the hospital; Characterized in the claim database is characterized by consisting of the step of examining the contents recorded in the Health Insurance Review and Assessment Service.

Advantages, preferred embodiments, and the like of the present invention will be more clearly understood from the following description, in comparison with the prior art, with reference to the accompanying drawings.

1 is a structural diagram showing a structure of a medical insurance claim authentication system of the present invention.

2 is a diagram showing a client system used in each server system used in the medical insurance claim authentication system of the present invention.

3 is a flow chart showing the flow of the medical insurance claim authentication method of the present invention.

Description of the main parts of the drawing

10: medical insurance card 20: hospital server system

25: billing database 30: health insurance collaborative server system

33: Subscriber database 35: Claim approval number database

40: Health Insurance Review & Assessment Service Server System 50: Credit Card Server System

1 is a structural diagram showing a structure of a medical insurance claim authentication system of the present invention. As shown in Figure 1, the medical insurance claim authentication system of the present invention, the medical insurance card 10 of the subscriber, the hospital server system 20, the health insurance corporation server system 30, the health insurance review and evaluation server system ( 40) and a credit card company server system 50.

The medical insurance card 10 of the subscriber according to the present invention is a card having a device capable of electronic processing such as a magnetic line, which is held by the medical insurance subscriber, and the number of the card is the health insurance corporation server system 30 ) Is linked to the subscriber's medical information. Medical insurance subscribers are presented with a medical insurance card (10) at the window of the hospital to confirm that they are medical insurance subscribers and that they are currently eligible for medical insurance. In addition, when storing the treatment fee at the hospital, the health insurance corporation server system 30 requests the billing approval number using the card number of the medical insurance card 10. The billing authorization number is associated with number (10) of the health insurance card. The card number for the health insurance is a code for the recognition of the subscriber.

Claim approval number according to the present invention is a means for the hospital to provide medical services to the medical insurance subscribers who are patients, the hospital informs the Health Insurance Corporation facts, and also to claim the medical insurance premiums. The hospital receives the bill approval number from the National Health Insurance Corporation, stores it for a certain period of time, and then uses it to collect the insurance premiums including the claim number and to claim the premiums incurred during the period.

The hospital server system 20 according to the present invention is a server system 20 of a hospital that performs a patient's duties such as patient reservations and patient information, and is connected to a network by a health insurance corporation server system 30 and a health insurance review and evaluation server. Means for communicating with the system 40 and the credit card company server system 50, and a billing database 25 for recording the details of the patient's medical history and medical expenses, etc. are provided. Through the hospital server system 20 can communicate with each server system, it is possible to record the details of the patient's medical treatment and medical expenses in the billing database (25). In addition, the hospital server system 20 is provided with means for reading the medical insurance card 10 of the subscriber. When the hospital diagnoses the patient and receives the medical expenses, the hospital requests the billing approval number to the Health Insurance Corporation using the hospital server system 20. Then, upon receiving the request for approval number, the doctor records the medical treatment of the patient in the hospital and the request for approval number provided by the Health Insurance Corporation in the billing database 25 using the hospital server system 20.

Health Insurance Corporation server system 30 according to the present invention is a server system of the Health Insurance Corporation and the subscriber database 33 for storing the information of the subscribers who enrolled in the medical insurance and the bill approval number received by requesting the Health Insurance Corporation from the hospital A claim approval database 35 is stored. The subscriber database 33 is a means for storing information on the health insurance subscribers. When the subscriber information established in the subscriber database 33 is checked by a credit card company and a hospital, the subscriber database 33 confirms that the medical insurance card 10 Issuance or request approval number from Health Insurance Corporation. When the medical insurance card 10 is issued, the medical insurance card 10 number is also recorded in the subscriber database 33. The bill approval number is provided by the Health Insurance Corporation upon request from the hospital to request medical billing for the medical insurance subscriber, and provides the bill approval number for the billing of the medical bill so that the hospital records the medical history and the bill approval number in the billing database (25). To help.

According to the present invention, the health insurance review and evaluation server system 40 is a server system of the health insurance review and evaluation, the health insurance review and evaluation inquiries provided by the Health Insurance Corporation by first querying the database of claim approval number established in the Health Insurance Service It is determined whether it is an approval number, and if the claim approval number provided by the National Health Insurance Service is correct, the medical record recorded in the claim database 25 is examined. The examination result is transmitted to the health insurance corporation server system 30 using the health insurance examination and evaluation server system 40.

The credit card company server system 50 according to the present invention issues a medical insurance card (10) to the health insurance subscribers by inquiring to the Health Insurance Corporation as a means of performing business in the credit card company, and also issued the card Make sure you pay the hospital for your care.

2 is a diagram showing a client system used in each server system used in the medical insurance claim authentication system of the present invention. Referring to FIG. 2, the client system used in the server system can communicate on a network using the TCP / IP protocol, and uses Windows or Unix as the operating system. In addition, the hospital, the Health Insurance Management Corporation, provides an application to electronically handle the work performed by the Health Insurance Review and Assessment Service. In addition, by providing an API (Application Program Interface) containing a module related to medical insurance information inquiry so that the function can be freely implemented in the application, it is possible to build a user-oriented UI (User Interface). APIs are used as a means for applications to formally request or communicate work with other programs. And, in order to avoid the difficulty of API connection directly in the application, a separate messenger type UI is provided so that the user can build the system more conveniently. Even if you provide a messenger-style UI, there is an API for messengers to connect to messengers. It can be more convenient in terms of use (linking to the system) than the existing low-level API.

3 is a flow chart showing the flow of the medical insurance claim authentication method of the present invention. Referring to Figure 3,

First step (ST 100): A person who wants to join prepares his / her details in a credit card company and applies for a subscription application and issuance of a medical insurance card 10 to use a medical insurance claim authentication service.

Step 2 (ST 110): If the application is made, the credit card company presents a detailed statement of the person who wants to join the health insurance corporation and asks whether the person can use the medical insurance claim certification service.

Third step (ST 120): If the person who wants to join in the credit card company can use the medical insurance claim authentication service, issuing a medical insurance card (10), provided in the Health Insurance Corporation server system (30) The health insurance card 10 number is stored in the subscriber database 33. The medical insurance card 10 stores a key value for inquiring and recognizing a subscriber, such as a medical insurance card number, and emergency medical information of the subscriber. If the person cannot use the medical insurance claim certification service, he / she will be notified of the fact that he cannot join.

Step 4 (ST 130): The member presents the medical insurance card 10 while requesting medical treatment at the hospital.

Step 5 (ST 140): The hospital provides a means for reading the medical insurance card 10 to the hospital server system 20 to determine whether the presenter of the card is a legitimate person who can use the medical insurance certification service. It is provided to compare the information on the medical insurance card 10 and the resident's card presenter to determine whether the person is a legitimate person. In addition, the Health Insurance Corporation checks whether the person can use the medical insurance certification service.

Step 6 (ST 150): The Health Insurance Corporation makes an inquiry using the information recorded in the subscriber database 33 when the hospital requests an inquiry. Medical insurance certification service cannot be used if the result of inquiry to the Health Insurance Corporation is not a legitimate person to use the medical insurance card, or if the information on the medical insurance card 10 and the information of the resident ID presented are different. To the cardholder

Step 7 (ST 160): If the person who presented the medical insurance card 10 is a legitimate person, the hospital conducts medical treatment and stores the medical expenses. Then, the hospital transmits the fact that the medical insurance subscriber received the medical treatment by using the number of the medical insurance card 10 to the health insurance corporation, and also requests the bill approval number from the health insurance corporation.

Step 8 (ST 170): The Health Insurance Corporation receives the request for the billing approval number from the hospital and the medical insurance of the medical insurance subscriber, and searches the medical insurance card (10) number and sends the billing approval number to the hospital if it is a true subscriber. do. When the hospital receives the request approval number sent by the Health Insurance Corporation, it records the request approval number in the claim database 25. In addition, the medical history and accommodation details (such as the medical bills charged to the patient) are recorded in the billing database 25.

Step 9 (ST 180): The contents recorded in the claim database 25 are reviewed by the Health Insurance Review and Assessment Service. The Health Insurance Review and Assessment Service first compares the claim number recorded in the claim database 25 with the claim number recorded in the claim number database 35 of the health insurance corporation server system 30 and records the result in the claim database 25. It is determined whether or not the claim approved approval number recorded in the claim approved approval number database 35 is the same. And, if the request approval number matches, the medical record recorded in the claim database 25 is examined to determine whether or not the medical expenses billing, over-care, etc. in the hospital.

Step 10 (ST 190): The results of the examination by the Health Insurance Review and Assessment Institute and the Claim Approval Number are linked to the Health Insurance Corporation, and the Health Insurance Corporation determines that the request is true by using the Claim Approval Number. The payment is made to the hospital according to the evaluation result.

In the medical insurance claim authentication system according to the present invention, the credit card company may not be a component of the system of the present invention. If the credit card company does not issue a medical insurance card associated with the credit card because it is not a unit of the medical insurance certification system of the present invention, the medical insurance subscriber has information about his / her medical insurance. You can get a card for health insurance issued by a health insurance corporation or a hospital. In such a case, after the medical insurance member receives the medical service at the hospital, the general member may choose to pay the cash or pay the card.

In addition, the medical insurance card according to the present invention stores the medical history for each medical insurance subscriber, for example, medical information about allergy, sensitivity to drugs, dementia, blood type, etc. If you look up the information through the terminal with the insurance card, you can find out the emergency medical information for the subscriber.

In the case of a large number of credit card companies, if a credit card company issued a medical insurance card, other credit card companies are regulated not to issue the same medical insurance card under the control of the Health Insurance Corporation.

According to the medical insurance claim authentication system and method of the present invention, by providing a medical insurance card, which is an electronic card to the subscriber so that the record of the subscriber's medical application and storage can be made electronically, the medical history of the subscriber in the hospital Make it easy to build data into a database.

In addition, since the receipt process is made electronically in the medical application and the hospital cannot change the contents recorded in the database, it is difficult to manipulate the records, so that the evaluation of the contents requested by the hospital can be easily performed by the auditor. Data can be built into the database to reduce the burden on personnel, help finance the Health Insurance Corporation, and prevent overpayment of health insurance costs.

In addition, since the member's medical history is recorded in the database, the contents of the database are reviewed by the evaluation and evaluation institute, and the doctor prevents the use of medical equipment unnecessary for the member's medical treatment, excessive use of antibiotics, etc. To benefit.

While the preferred embodiments of the present invention have been described using specific terms, such descriptions are for illustrative purposes only, and it is understood that various changes and modifications may be made without departing from the spirit and scope of the following claims. Should be done.

Claims (8)

Medical insurance claim certification system that manages medical insurance finances by reviewing medical insurance details requested by hospitals. A medical insurance card which is electronically processed by a subscriber who has subscribed to the medical insurance; A hospital server system including means for reading the card for medical insurance, a billing database for storing the medical history and the storage of the hospital; A health insurance corporation server system having means for holding information on the holder of the card for medical insurance; And And a health care claim authentication system connected to the billing database and configured to allow the auditor evaluation server system to review the contents recorded in the billing database. The method of claim 1, The medical insurance claim authentication system, characterized in that the identification code of the medical insurance card possessed by the subscriber is linked to the medical information for the subscriber corresponding to the card stored in the health insurance corporation server system. The method according to claim 1 or 2, The medical insurance card is a medical insurance claim authentication system, characterized in that issued by a credit card company. The method according to any one of claims 1 to 3, And claim means for storing a claim number in the health insurance corporation server system. The method of claim 1, The medical insurance card stores emergency medical information such as allergy, dementia, blood type, etc. corresponding to the medical history of the holder of the medical insurance card, and can be searched with the medical insurance card. Medical insurance claim certification system. Medical insurance claim authentication method that manages medical insurance finances by reviewing medical insurance details requested by the hospital. Presenting a medical insurance card while the subscriber requests medical care at a hospital; Determining whether the person presenting the card is a legitimate person who can use the medical insurance certification service; Transmitting a request for approval number from the health insurance corporation to the hospital when the hospital requests a request for approval from the health insurance corporation; Storing the claim approval number in the health insurance corporation; Storing the medical history and the billing approval number of the subscriber in a billing database in the hospital; And The health insurance claim authentication method comprising the step of examining the contents recorded in the claim database in the Health Insurance Review and Assessment Service. The method of claim 6, Before presenting the medical insurance card, The subscriber filling out his / her detailed statement with a credit card company and applying for issuance of a medical insurance card and issuance of a medical insurance card; If the application, the credit card company requesting the inquiry whether the person who can use the health insurance claim authentication service by presenting a new statement of the person who wants to join the Health Insurance Corporation; And If the person who wants to join the credit card company can use the medical insurance claim authentication service, the medical insurance claim authentication method further comprising the step of issuing a medical insurance card. The method according to any one of claims 6 to 7, In the stage of the health insurance review evaluation, Comprising the claim approval number stored in the Health Insurance Corporation and claim approval number recorded in the claim database further comprises the step of checking the medical insurance claim authentication method.