WO2019100595A1 - 保险理赔案件互斥信息的确定方法及装置 - Google Patents

保险理赔案件互斥信息的确定方法及装置 Download PDF

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Publication number
WO2019100595A1
WO2019100595A1 PCT/CN2018/075403 CN2018075403W WO2019100595A1 WO 2019100595 A1 WO2019100595 A1 WO 2019100595A1 CN 2018075403 W CN2018075403 W CN 2018075403W WO 2019100595 A1 WO2019100595 A1 WO 2019100595A1
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Prior art keywords
mutual exclusion
disease
information
data
identification code
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PCT/CN2018/075403
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English (en)
French (fr)
Inventor
李响
和婷
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平安科技（深圳）有限公司
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Publication of WO2019100595A1 publication Critical patent/WO2019100595A1/zh

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    • G—PHYSICS
    • G06—COMPUTING; CALCULATING OR COUNTING
    • G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
    • G06Q40/00—Finance; Insurance; Tax strategies; Processing of corporate or income taxes
    • G06Q40/08—Insurance

Definitions

  • the present application relates to the field of data processing technologies, and in particular, to a method and an apparatus for determining mutual exclusion information of an insurance claims case.
  • the insurance industry's underwriting personnel need to approve the proofreading case in order to accurately make claims and reduce the risk of claims.
  • the underwriting personnel need to manually check each claim item in the claim case and determine whether there is an abnormality of the claim.
  • the present application provides a method and a device for determining mutual exclusion information of insurance claims cases, and the main purpose thereof is to solve the problem that the existing specific claims items and treatment items in the claim cases are not in accordance with common sense, that is, mutual exclusion. Vulnerabilities are prone to occur during manual audits. For example, the judgment of whether there is mutual exclusion information in past medical history, surgical records, joint insurance relationship, and blacklist will vary from person to person, resulting in wrong judgment and missed judgment, increasing the risk of claims. And manual review also wastes a lot of human resources and reduces the efficiency of auditing.
  • a method for determining mutual exclusion information of an insurance claims case including:
  • the method further includes:
  • the mutual exclusion information does not exist in the claim data, obtaining the historical policy information of the insured; and determining whether the primary connection relationship and the contact information in the historical policy information are mutually exclusive, if there is mutual exclusion In the case, the flag and the display are performed. If there is no mutual exclusion, it is determined whether the historical policy information is recorded in the preset blacklist, and if so, the tag and the display are performed.
  • the method for configuring the preset mutual exclusion rule in the method includes:
  • a logical relationship the logical relationship is used to reflect a mutual exclusion between the age and gender after the identifier code replaces the disease and medical information; and the logical relationship is determined as a preset mutual exclusion rule.
  • determining whether the mutual exclusion information exists in the claim data according to the preset mutual exclusion rule includes:
  • the situation is based on the mutual exclusion of age and disease, the mutual exclusion of gender and disease, the mutual exclusion of related diseases after a one-time operation, the mutual exclusion of the same person due to disease, and the disease of a special disease group.
  • the logical relationship between the mutual exclusion of the treatment, the mutual exclusion of the disease and the inspection project, and the configuration of the claims data includes:
  • the situation, the preset correspondence relationship between the disease and the inspection item mutually exclusive, and the age, the disease identification code, the gender, and the medical treatment identification code are generated as 0 and 1 identifiers according to the preset correspondence relationship. Multidimensional space vector.
  • the method further includes:
  • the warning information is sent, and the claim case corresponding to the mutually exclusive information with the mark is displayed for the user to perform manual review.
  • an apparatus for determining mutual exclusion information of an insurance claim case including:
  • a first obtaining unit configured to obtain claim data of the insured in the claim case; the first determining unit is configured to determine, according to the preset mutual exclusion rule, whether the mutual exclusion information exists in the claim data, and the preset mutual exclusion rule And a marking unit configured to mark the mutually exclusive information if mutual exclusion information exists.
  • the device further includes: a second acquiring unit, configured to acquire historical policy information of the insured if the mutual exclusion information does not exist in the claim data; and a second determining unit, configured to separately determine Whether the main affiliation relationship and the contact information in the historical policy information are mutually exclusive. If there is a mutual exclusion, the tag and the display are performed. If there is no mutual exclusion, it is determined whether the historical policy information is recorded in the preset. In the blacklist, if yes, mark and display.
  • a storage medium stores at least one executable instruction, the executable instruction causing a processor to execute a method for determining mutual exclusion information of the insurance claim case. operating.
  • a terminal including: a processor, a memory, a communication interface, and a communication bus, wherein the processor, the memory, and the communication interface complete mutual communication through the communication bus ;
  • the memory is configured to store at least one executable instruction, the executable instruction causing the processor to perform an operation corresponding to the determining method of the insurance claim case mutual exclusion information.
  • the technical solution provided by the embodiment of the present application has at least the following advantages:
  • the present application provides a method and a device for determining mutual exclusion information of an insurance claim case, first obtaining the claim data of the insured in the claim case, and then determining whether there is mutual exclusion information in the claim data according to the preset mutual exclusion rule.
  • the preset mutual exclusion rule is used to reflect the mutually exclusive relationship in the claim data. If mutual exclusion information exists, the mutual exclusion information is marked. Whether it is mutually exclusive with the specific claims items and treatment items in the claim cases, the manual review is prone to loopholes, resulting in wrong judgments and missed judgments, increasing the risk of claims, and manual review also wastes a lot of human resources.
  • the embodiment of the present application determines whether there is a mutual exclusion in the claim data according to the preset mutual exclusion rule of the mutually exclusive relationship in the response claim data, and if there is a mark for further manual review To reduce the staff's operational knowledge requirements, improve the accuracy and accuracy of audit claims, and reduce the risk of claims.
  • FIG. 1 is a flowchart of a method for determining mutual exclusion information of an insurance claim case according to an embodiment of the present application
  • FIG. 2 is a flowchart of a method for determining mutual exclusion information of another insurance claim case provided by an embodiment of the present application
  • FIG. 3 is a block diagram of a device for determining mutual exclusion information of an insurance claim case according to an embodiment of the present application
  • FIG. 4 is a block diagram of a device for determining mutual exclusion information of another insurance claim case provided by an embodiment of the present application
  • FIG. 5 is a schematic diagram of a terminal provided by an embodiment of the present application.
  • the embodiment of the present application provides a method for determining mutual exclusion information of an insurance claim case. As shown in FIG. 1 , the method includes:
  • the insured refers to a person who has the right to claim the insurance premium after the occurrence of the insured event according to the effective insurance contract
  • the claim case is a case arising from the insured person's insured item specified in the insured product.
  • the claims data includes the age, sex, disease, and medical treatment data of the insured when the claim is insured. For example, if the insured is Xiao Wang, the age at the time of claim settlement is 30, the gender is female, and the disease is uterine cancer.
  • the diagnosis and treatment data during the treatment include surgical treatment for the removal of the uterus and chemotherapy.
  • the claim data is also divided into the historical claim data of the historical claims case and the current claims data of the current claim case. The historical claim case is relative to all claim cases before the current claims case.
  • the current claim case is used as the current claim data. It will be used as historical claim data for all claims before this time. It should be noted that if there is no historical claim data in the claim data of the insured, it indicates that the insured has no claims event before the occurrence of the current claim case, that is, the current claim data can be directly judged. In addition, due to the large number of insured persons insured in insurance companies, all insured claims will be entered into the insurance database in the form of data after they occur, so that they can be extracted and used when they need to be reviewed or checked.
  • the preset mutual exclusion rule is configured to reflect a mutually exclusive relationship in the claim data, where the mutual exclusion is a mutually exclusive logical relationship, for example, the sex of the insured is male, and the disease is uterine cancer. It is impossible for normal men to exist, and this situation is mutually exclusive.
  • the preset mutual exclusion rule stores all mutual exclusion situations between the age, sex, disease, and treatment data during the treatment period. For example, the insured person is 20 years old and has the disease as senile purpura. However, for a normal person under the age of 35, it is impossible to have senile purpura. Therefore, the age group is under 35 years old and the disease is senile purpura.
  • the embodiment of the present application is not specifically limited.
  • determining whether the mutually exclusive information in the claim data further includes the current claim data and the historical claim data, for example, the medical treatment data during the treatment of the historical claim data is for removing the right kidney, and the current claim data is during the treatment period.
  • the diagnosis and treatment data is to diagnose the right kidney stone. For the normal removal of the right kidney, the cause of the right kidney stone does not appear, indicating that there is mutual exclusion information in the historical claim data and the current claim data.
  • the preset mutual exclusion rule may specifically include a mutual exclusion relationship between age and disease, a mutual exclusion relationship between gender and disease, a mutual exclusion relationship between related diseases, and a mutually exclusive relationship between different diseases.
  • the specific age groups and the diseases are mutually exclusive, and the specific gender and which diseases are Mutually exclusive relationships, which diseases are mutually exclusive, specific diseases are mutually exclusive differences, and specific diseases of specific populations are mutually exclusive.
  • the mutual exclusion information needs to be marked so that the auditors can directly extract the cases in which the mutually exclusive information appears, thereby improving the efficiency of the audit. It should be noted that if there is no mutually exclusive information in the claim data, it indicates that the current claim data is a normal claim case, and the insurance company can perform normal claim.
  • the present application provides a method for determining the mutual exclusion information of insurance claims cases, and whether there is mutual exclusion between the specific claims items and the treatment items in the claim cases, and the manual review is prone to loopholes, resulting in wrong judgments and missed judgments.
  • the claim risk is increased, and the manual review also wastes a lot of human resources and reduces the efficiency of the audit.
  • the embodiment of the present application determines whether the claim data is in the claim data. There is a mutual exclusion situation. If there is a markup for further manual review, the staff's operational knowledge level requirements are reduced, the accuracy and accuracy of the audit claims case are improved, and the claim risk is reduced.
  • the embodiment of the present application provides another method for determining mutual exclusion information of an insurance claim case. As shown in FIG. 2, the method includes:
  • step 102 is the same as the method in step 102 shown in FIG. 1, and details are not described herein again.
  • the claim data of different insured persons are stored according to the single number of the policy, and each claim number corresponding to the insured is corresponding to each claim number, so as to When the obtaining step is performed, the claim data is directly obtained according to the policy number of the insured in the claim case, wherein the policy number can be the main single number or the single order number, which is not specifically limited in the embodiment of the present application.
  • the claim data is mutually exclusive with the preset.
  • the medical treatment information includes a one-time surgical treatment item, a medical treatment disease, an examination item, and the like, and the logical relationship is used to reflect the identification code replacement.
  • the mutual exclusion between the disease and the age, gender, and medical information includes: the mutual exclusion of age and disease, the mutual exclusion of gender and disease, and the mutual exclusion of related diseases after a single operation.
  • the case where the same person is mutually exclusive due to the disease, the case where the special disease group is mutually exclusive due to the disease, and the case where the disease and the examination item are mutually exclusive are not specifically limited in the embodiment of the present application.
  • the mutually exclusive information in the claim data is extracted for manual review, which improves the accuracy and efficiency of the audit.
  • age and disease mutual exclusion including the diseases that are impossible for each age group
  • the age group will be divided into three, namely: age ⁇ 16, 16 ⁇ age ⁇ 35, Age > 55, such as 15 years old people with senile purpura are mutually exclusive.
  • gender and disease mutual exclusion there are two cases, “male has female disease” and “female suffers from male disease”.
  • mutually exclusive illness can exist in the form of a corresponding list, for example, The disease is the pelvic peritoneum and the chlamydial infection of the genitourinary organs, which corresponds to the male, is a mutually exclusive situation.
  • the diagnosis and treatment information in the historical claim data of the insured is hypertensive retinopathy
  • the diagnosis and treatment information in the current claim data is idiopathic hypotension, which is mutually exclusive.
  • the diagnosis and treatment information in the current claim data is idiopathic hypotension, which is mutually exclusive.
  • the diagnosis and treatment information in the historical claims data is abdominal pregnancy
  • the diagnosis and treatment information in the current claim data is hypertensive retinopathy, which is a mutual exclusion.
  • the disease and examination items are mutually exclusive, including the inspection items that are not related to the disease, that is, if the same person with the disease does not have an examination related to the disease, such as the diagnosis information of the current claim data.
  • the recorded item is a retinal examination, which is a mutually exclusive situation.
  • the specific age, disease, gender, and medical treatment information may be stored in the form of a program code.
  • the example is not specifically limited.
  • all the disease names published in the current World Health Organization information on disposable medical treatment items, medical treatment diseases, and examination items in the medical treatment information are also consistent with the corresponding names published by the World Health Organization.
  • the example is not specifically limited.
  • the age, the age, the mutual exclusion of the disease, the gender and the disease may be separately judged according to the sequence.
  • the method for configuring the preset mutual exclusion rule in step 202 includes: acquiring project data of all diseases, and using the subject of the disease and the type of diagnosis and treatment as the basis for generating the identification code, and the project is in accordance with the sequence.
  • the medical treatment information and the disease order in the data are obtained by the identification code corresponding to the medical treatment information and the disease, and the disease in the claim data is replaced with a corresponding identification code, and the medical treatment information in the claim data is replaced.
  • Corresponding identification code the situation of mutual exclusion of age and disease, the mutual exclusion of gender and disease, the mutual exclusion of related diseases after one-time operation, the mutual exclusion of the same person due to illness, and the cause of special diseases
  • the logical relationship between the disease treatment and the exclusion of the disease and the examination item configures the logical relationship of the claim data, and the logical relationship is used to reflect the identification code after replacing the disease and the diagnosis information with the age and gender.
  • Mutually exclusive determining the logical relationship as a preset mutual exclusion rule.
  • the project data of all the diseases is information such as diseases, treatment items, examination items and the like published by the World Health Organization, and the identification code is used for uniquely identifying diseases and medical treatment information, so as to simplify the matching and searching steps of the diseases.
  • the subjects of the disease may be subjects according to different body parts, for example, ophthalmology, internal medicine, gynecology, etc., and the examples in the present application are not specifically limited, and the type of diagnosis and treatment is the name of the treatment for treating diseases and the name of the examination, for example, B-ultrasound, CT
  • the examination, the six tests of female hormones, etc. are not specifically limited in the examples of the present application, and the order may be the order of arranging disease identification codes according to internal medicine, surgery, endocrine circulation, gynecology, pediatrics, orthopedics, and the like.
  • the embodiment of the present application is not specifically limited in order to arrange the medical treatment information identification code according to the blood test type, the X-ray examination type, and the like.
  • the logical relationship of configuring the claim data according to the identification code includes performing a multi-to-many correspondence between the disease identification code and the age, gender, and medical identification code according to the logic of the mutual exclusion condition, and obtaining a multi-dimensional correspondence relationship, from which the correspondence relationship is obtained. It can be clearly found that there is a mutual exclusion relationship between the disease identification code of a disease and the age, gender, and medical identification code. For example, there is a list of ICDs in the bottom layer of the database, including D69.202 for senile purpura.
  • ICD, A56.100 is the ICD of the pelvic peritoneum and chlamydial infection of genitourinary organs
  • SURG.F03117 is the ICD of one-time transabdominal hysterectomy
  • I95.000 is ICD of idiopathic hypotension
  • H35. 004 is an ICD or the like of hypertensive retinopathy, and is not specifically limited in the embodiment of the present application.
  • the pre-existing rules are obtained through the logical relationship between the age, the disease identification code, the gender, and the mutual exclusion between the medical identification codes, so that the mutual exclusion condition that does not conform to the normal logic can be determined without human judgment, and the audit efficiency is increased. And accuracy.
  • the situation is mutually exclusive according to age and disease, the situation of mutual exclusion of gender and disease, the mutual exclusion of related diseases after one-time operation, the mutual exclusion of the same person due to disease, and the special disease.
  • the logical relationship between the population due to the disease and the mutual exclusion of the disease and the inspection project includes the mutual exclusion of age and disease, the mutual exclusion of gender and disease, and the association after one-time operation.
  • the mutual exclusion of disease visits, the mutual exclusion of the same person due to illness, the mutual exclusion of patients with special diseases due to disease, and the mutual exclusion of diseases and inspection items, according to the preset correspondence
  • the age, disease identification code, gender, and visit identification code generate a multi-dimensional space vector having a 0, 1 identifier as a row and a column of the vector.
  • the age and disease are mutually exclusive
  • the gender and disease are mutually exclusive
  • the mutual exclusion of related diseases after a one-time operation the mutual exclusion of the same person due to illness
  • the special disease population are mutually exclusive due to disease treatment.
  • the preset correspondence relationship between the situation, the disease and the inspection item mutually exclusive is set by the technician, and the corresponding relationship includes the specific situation between the age, the disease identification code, the gender, and the medical identification code, and then generated.
  • a space vector of a multidimensional mapping relationship is a logical relationship.
  • the multidimensional space vector includes 1, 0 elements, rows and columns represent age, disease, gender, diagnosis and treatment information, identification code, 1 is "mutual exclusion", 0 is " For example, the age of the row vector element is 10, the identifier of the column vector element is D69.202, and the mutual exclusion in the vector is determined to be 1, which is not specifically limited in the embodiment of the present application.
  • the age, the disease identification code, the gender, and the diagnosis and treatment identification code in the claim data can be queried correspondingly, and no manual verification is needed to improve the audit efficiency.
  • the mutually exclusive information includes the exclusive content of the age, the disease identification code, the gender, and the medical identification code, so that the staff can perform manual review.
  • the mark may be in the form of marking the mutual exclusion information as positive, or may be marked as red, etc., and the information that is not mutually exclusive may not be marked, or may be marked as negative or green, etc., which is not specifically limited in the embodiment of the present application.
  • the claim data of the mutual exclusion situation may be marked for the occurrence of a mutually exclusive information, and the other data is no longer judged, and all the mutually exclusive information may be determined and marked, which is not specifically limited in the embodiment of the present application. .
  • step 203b along with step 203a, if there is no mutually exclusive information in the claim data, the insured's historical policy information is acquired.
  • the insured's historical policy information may be policy information or sub-sale information, and specifically includes a splicing relationship, a blacklist information, and contact information, and is not specifically limited in this embodiment.
  • the step 204 after the step 203b determines whether the primary connection relationship and the contact information in the historical policy information are mutually exclusive. If there is a mutual exclusion, the flag and the display are performed. In the case of mutual exclusion, it is determined whether the historical policy information is recorded in the preset blacklist, and if so, marking and displaying.
  • the main collateral relationship includes retrieving the associated information of the main historical policy according to the customer number and the document number, that is, the associated information is between the policyholder, the insured, the main order, the sub-order, the policyholder and the insured
  • the relationship such as a spouse, a child, a parent, etc., is not specifically limited in this application.
  • the contact information includes a contact telephone number and a contact email address
  • the preset blacklist includes hospital information, policyholder information, and black information of the insured person information.
  • the blacklist may be added in a manner that does not pay on time, the amount of the claim exceeds a predetermined value, or other blacklists are listed.
  • the mutual exclusion of the primary connected relationship is that if the name, the document number and the historical record of the associated information are inconsistent, the mutual exclusion is performed, and the mutual exclusion of the contact information includes the use of the same telephone number or mailbox by multiple persons. If the number of the sub-orders is inconsistent, the number of the ones in the historical policy information stored in the system is a mutual exclusion.
  • the telephones corresponding to the two sub-numbers are the same.
  • the mutual exclusion of the preset blacklist is that the insured, the insured, the hospital, and the like in the policy information are mutually exclusive in the preset blacklist, and the preset blacklist hospital may appear.
  • the medical malpractice hospital, or the lower-level hospital, the preset blacklist unit is the person or the unit whose insured person does not pay the insurance on time, and the embodiment of the present application does not specifically limit.
  • step 205 after steps 203a and 204, the warning information is sent, and the claim case corresponding to the mutually exclusive information with the mark is displayed.
  • the warning information may be an audible prompt information, a dialog box prompting information, and the like, so that the user can perform manual auditing, which is not specifically limited in the embodiment of the present application.
  • the present application provides another method for determining mutual exclusion information of insurance claims cases.
  • the embodiment of the present application searches for the logical relationship between the age, the disease identification code, the gender, and the medical identification code in the claim data and the preset mutual exclusion rule. Matching to determine whether there is a mutual exclusion. If it does not exist, further determine whether there is a primary connection, contact information, and mutual exclusion of the blacklist in the historical policy information. If yes, mark it for further Manual review, to simplify the complicated steps of manual review, reduce the staff's operational knowledge requirements, improve timeliness, reduce the time for reviewing claims, improve the accuracy and accuracy of audit claims, and reduce the risk of claims.
  • the embodiment of the present application provides a device for determining mutual exclusion information of an insurance claim case.
  • the device includes: a first acquiring unit 31, and a first The judging unit 32 and the marking unit 33.
  • the first obtaining unit 31 is configured to acquire the claim data of the insured in the claim case; the first obtaining unit 31 is configured to execute the claim module for obtaining the claim data of the insured in the claim case for the determining device of the insurance claim case mutual exclusion information. .
  • the first determining unit 32 is configured to determine, according to the preset mutual exclusion rule, whether mutual exclusion information exists in the claim data, where the preset mutual exclusion rule is used to reflect a mutually exclusive relationship in the claim data;
  • the determining unit 32 performs a program module for determining whether the mutual exclusion information exists in the claim data according to the preset mutual exclusion rule for the determining device of the insurance claim case mutual exclusion information.
  • the marking unit 33 is configured to mark the mutually exclusive information if mutual exclusion information exists.
  • the marking unit 33 performs a program module for marking the mutually exclusive information for the determining device of the insurance claim case mutual exclusion information.
  • the present application provides a device for determining mutual exclusion information of insurance claims cases, and whether there is mutual exclusion between the specific claims items and the treatment items in the claim cases, and the loops are prone to loopholes during manual review, resulting in wrong judgments and missed judgments of the audits.
  • the claim risk is increased, and the manual review also wastes a lot of human resources and reduces the efficiency of the audit.
  • the embodiment of the present application determines whether the claim data is in the claim data. There is a mutual exclusion situation. If there is a markup for further manual review, the staff's operational knowledge level requirements are reduced, the accuracy and accuracy of the audit claims case are improved, and the claim risk is reduced.
  • the embodiment of the present application provides another apparatus for determining mutual exclusion information of an insurance claim case.
  • the apparatus includes: a first acquiring unit 41, A judging unit 42, a marking unit 43, a second obtaining unit 44, a second judging unit 45, and a transmitting unit 46.
  • the first obtaining unit 41 is configured to obtain claim data of the insured in the claim case, and the first determining unit 42 is configured to determine, according to the preset mutual exclusion rule, whether mutual exclusion information exists in the claim data, where the preset mutual The repulsion rule is used to reflect the mutually exclusive relationship in the claim data; the marking unit 43 is configured to mark the mutually exclusive information if mutual exclusion information exists.
  • the device further includes:
  • the second obtaining unit 44 is configured to acquire the historical policy information of the insured if the mutual exclusion information does not exist in the claim data, and the second determining unit 45 is configured to separately determine the main in the historical policy information. If there is a mutual exclusion, if there is a mutual exclusion, mark and display, if there is no mutual exclusion, determine whether the historical policy information is recorded in the preset blacklist, and if so, Mark and display.
  • the first determining unit 42 includes: an obtaining module 4201, configured to acquire item data of all diseases, and use the subject of the disease and the type of diagnosis and treatment as the basis for generating the identification code, and the item data according to the order.
  • the medical treatment information and the disease ranking are obtained by the identification code corresponding to the medical treatment information and the disease, and the disease in the claim data is replaced with a corresponding identification code, and the medical treatment information in the claim data is replaced with Corresponding identification code;
  • configuration module 4202 for mutual exclusion of age and disease, mutual exclusion of gender and disease, mutual exclusion of related diseases after one-time operation, and mutual exclusion of the same person due to illness
  • the logical relationship between the special disease population due to the mutual exclusion of the disease and the mutual exclusion of the disease and the examination item, and the logical relationship is used to reflect the age after the identification code replaces the disease and the diagnosis information.
  • the mutual exclusion between the genders; the determining module 4203 is configured to determine the logical relationship as a preset mutual ex
  • the first determining unit 42 is specifically configured to separately parse the age, the disease identification code, the gender, and the medical treatment identification code in the claim data, and set the age, the disease identification code, the gender, and the diagnosis identifier of the claim data.
  • the code is matched to the preset mutual exclusion rule, and the mutual exclusion information is determined in the claim data according to the logical relationship in the preset mutual exclusion rule.
  • the configuration module 4202 is specifically configured to separately acquire the mutual exclusion of the age and the disease, the mutual exclusion of the gender and the disease, the mutual exclusion of the related diseases after the one-time operation, and the mutual treatment of the same person due to the disease.
  • the predicated correspondence between the disfigurement, the special disease population due to the disease, the mutual exclusion of the disease and the examination item, and the age, disease identification code, gender, and medical identification code according to the preset correspondence A multi-dimensional space vector having a 0, 1 identifier is generated as a row and a column of the vector.
  • the device further includes: a sending unit 46, configured to send the warning information, and display the claim case corresponding to the marked mutual exclusion information, so that the user performs manual review.
  • a sending unit 46 configured to send the warning information, and display the claim case corresponding to the marked mutual exclusion information, so that the user performs manual review.
  • the present application provides another apparatus for determining mutual exclusion information of insurance claims cases.
  • the embodiment of the present application searches for the logical relationship between the age, the disease identification code, the gender, the medical identification code, and the preset mutual exclusion rule in the claim data. Matching to determine whether there is a mutual exclusion. If it does not exist, further determine whether there is a primary connection, contact information, and mutual exclusion of the blacklist in the historical policy information. If yes, mark it for further Manual review, to simplify the complicated steps of manual review, reduce the staff's operational knowledge requirements, improve timeliness, reduce the time for reviewing claims, improve the accuracy and accuracy of audit claims, and reduce the risk of claims.
  • FIG. 5 is a schematic structural diagram of a terminal according to an embodiment of the present application.
  • the terminal may include: a processor 502, a communication interface (Communications) Interface 504, memory 506, and communication bus 508.
  • the processor 502, the communication interface 504, and the memory 506 complete communication with each other via the communication bus 508.
  • the communication interface 504 is configured to communicate with network elements of other devices, such as clients or other servers.
  • the processor 502 is configured to execute the program 510, and specifically, the related steps in the foregoing method for determining the mutual exclusion information of the insurance claims case.
  • program 510 can include program code, the program code including computer operating instructions.
  • the processor 502 may be a central processing unit CPU or a specific integrated circuit ASIC (Application) Specific Integrated Circuit), or one or more integrated circuits configured to implement embodiments of the present application.
  • ASIC Application Specific Integrated Circuit
  • the one or more processors included in the terminal may be the same type of processor, such as one or more CPUs; or may be different types of processors, such as one or more CPUs and one or more ASICs.
  • the memory 506 is configured to store the program 510.
  • Memory 506 may include high speed RAM memory and may also include non-volatile memory (non-volatile memory) Memory), such as at least one disk storage.
  • Program 510 can be specifically configured to cause processor 502 to perform the following operations:
  • modules in the devices of the embodiments can be adaptively changed and placed in one or more devices different from the embodiment.
  • the modules or units or components of the embodiments may be combined into one module or unit or component, and further they may be divided into a plurality of sub-modules or sub-units or sub-components.
  • any combination of the features disclosed in the specification, including the accompanying claims, the abstract and the drawings, and any methods so disclosed, or All processes or units of the device are combined.
  • Each feature disclosed in this specification (including the accompanying claims, the abstract and the drawings) may be replaced by alternative features that provide the same, equivalent or similar purpose.
  • the various component embodiments of the present application can be implemented in hardware, or in a software module running on one or more processors, or in a combination thereof. It should be understood by those skilled in the art that a microprocessor or a digital signal processor (DSP) can be used in practice to implement the method and apparatus for determining the mutual exclusion information of the insurance claims case according to the embodiments of the present application. Some or all of the features.
  • the application can also be implemented as a device or device program (e.g., a computer program and a computer program product) for performing some or all of the methods described herein.
  • Such a program implementing the present application may be stored on a computer readable medium or may be in the form of one or more signals. Such signals may be downloaded from an Internet website, provided on a carrier signal, or provided in any other form.

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Abstract

一种保险理赔案件互斥信息的确定方法及装置，涉及数据处理技术领域，该方法包括：获取理赔案件中被保险人的理赔数据（101）；根据预置互斥规则判断所述理赔数据中是否存在互斥信息（102），所述预置互斥规则用于反应所述理赔数据中的互斥关系；若存在互斥信息，则对所述互斥信息进行标记（103）。该方法解决了对于现有理赔案件中的具体理赔项目与治疗项目是否存在互斥，人工审核时容易出现漏洞，造成审核的错判、漏判，增加了理赔风险，且人工审核还浪费了大量的人力资源，降低审核的效率的问题。

Description

保险理赔案件互斥信息的确定方法及装置
本申请要求与2017年11月22日提交中国专利局、申请号为201711180305.5、发明名称为“保险理赔案件互斥信息的确定方法和装置”的中国专利申请的优先权，其全部内容通过引用结合在申请中。
技术领域
本申请涉及一种数据处理技术领域，特别是涉及一种保险理赔案件互斥信息的确定方法及装置。
背景技术
在保险理赔案件发生后，保险行业的核保人员需要对理赔案件进行核准校对，以便准确进行理赔并降低理赔案件来带的理赔风险。其中，为了对确保理赔案件的准确性，核保人员需要人工对理赔案件中各个理赔项目进行核对，并判断是否存在理赔的异常现象。
目前，现有理赔案件的审核都是通过核保人员进行人工审核，需要审核被保人的投保信息与定损信息是否出现一些不符合常理的情况，但是，对于理赔案件中的具体理赔项目与治疗项目是否存在不符合常理的情况，即互斥情况，人工审核时容易出现漏洞，例如，既往病史、手术记录、连带投保关系以及黑名单等方面是否出现互斥信息的判断会因人而异，造成审核的错判、漏判，增加了理赔风险，且人工审核还浪费了大量的人力资源，降低审核的效率，因此，对保险理赔案件互斥信息的确定已经成为亟待解决的问题。
发明内容
有鉴于此，本申请提供一种保险理赔案件互斥信息的确定方法及装置，主要目的在于解决现有对于理赔案件中的具体理赔项目与治疗项目是否存在不符合常理的情况，即互斥情况，人工审核时容易出现漏洞，例如，既往病史、手术记录、连带投保关系以及黑名单等方面是否出现互斥信息的判断会因人而异，造成审核的错判、漏判，增加了理赔风险，且人工审核还浪费了大量的人力资源，降低审核的效率的问题。
依据本申请一个方面，提供了一种保险理赔案件互斥信息的确定方法，包括：
获取理赔案件中被保险人的理赔数据；根据预置互斥规则判断所述理赔数据中是否存在互斥信息，所述预置互斥规则用于反应所述理赔数据中的互斥关系；若存在互斥信息，则对所述互斥信息进行标记。
进一步地，所述根据预置互斥规则判断所述理赔数据中是否存在互斥信息之后，所述方法还包括：
若所述理赔数据中不存在互斥信息，则获取所述被保险人的历史保单信息；分别判断所述历史保单信息中的主被连带关系、联系信息是否存在互斥情况，若存在互斥情况，则进行标记以及展示，若不存在互斥情况，则判断所述历史保单信息是否记录在预置黑名单中，若是，则进行标记以及展示。
进一步地，所述方法中预置互斥规则的配置方法包括：
获取全部疾病的项目数据，将疾病的科目及诊疗的类型作为生成标识码的顺序依据，按照所述顺序对所述项目数据中的诊疗信息及疾病排序得到与所述诊疗信息及疾病一一对应的标识码，并将所述理赔数据中的疾病替换为对应的标识码，以及将所述理赔数据中的诊疗信息替换为对应的标识码；根据年龄与疾病互斥的情况、性别与疾病互斥的情况、一次性手术后因关联疾病就诊互斥的情况、同一人因疾病就诊互斥的情况、特殊疾病人群因疾病就诊互斥的情况、疾病与检查项目互斥的情况配置理赔数据的逻辑关系，所述逻辑关系用于反应所述标识码替代所述疾病及诊疗信息后与所述年龄、性别之间的互斥情况；将所述逻辑关系确定为预置互斥规则。
进一步地，所述根据预置互斥规则判断所述理赔数据中是否存在互斥信息包括：
分别解析所述理赔数据中的年龄、疾病标识码、性别以及诊疗标识码；将所述理赔数据的年龄、疾病标识码、性别以及诊疗标识码匹配至所述预置互斥规则中，并根据所述预置互斥规则中的逻辑关系确定所述理赔数据中是否存在互斥信息。
进一步地，所述根据年龄与疾病互斥的情况、性别与疾病互斥的情况、一次性手术后因关联疾病就诊互斥的情况、同一人因疾病就诊互斥的情况、特殊疾病人群因疾病就诊互斥的情况、疾病与检查项目互斥的情况配置理赔数据的逻辑关系包括：
分别获取根据年龄与疾病互斥的情况、性别与疾病互斥的情况、一次性手术后因关联疾病就诊互斥的情况、同一人因疾病就诊互斥的情况、特殊疾病人群因疾病就诊互斥的情况、疾病与检查项目互斥的情况的预设对应关系，根据所述预设对应关系将所述年龄、疾病标识码、性别、就诊标识码作为向量的行及列生成具有0、1标识的多维空间向量。
进一步地，所述若存在互斥信息，则对所述互斥信息进行标记之后，所述方法还包括：
发送预警信息，并将带有标记的互斥信息对应的理赔案件进行展示，以便用户进行人工审核。
依据本申请一个方面，提供了一种保险理赔案件互斥信息的确定装置，包括：
第一获取单元，用于获取理赔案件中被保险人的理赔数据；第一判断单元，用于根据预置互斥规则判断所述理赔数据中是否存在互斥信息，所述预置互斥规则用于反应所述理赔数据中的互斥关系；标记单元，用于若存在互斥信息，则对所述互斥信息进行标记。
进一步地，所述装置还包括：第二获取单元，用于若所述理赔数据中不存在互斥信息，则获取所述被保险人的历史保单信息；第二判断单元，用于分别判断所述历史保单信息中的主被连带关系、联系信息是否存在互斥情况，若存在互斥情况，则进行标记以及展示，若不存在互斥情况，则判断所述历史保单信息是否记录在预置黑名单中，若是，则进行标记以及展示。
根据本申请的又一方面，提供了一种存储介质，所述存储介质中存储有至少一可执行指令，所述可执行指令使处理器执行如上述保险理赔案件互斥信息的确定方法对应的操作。
根据本申请的再一方面，提供了一种终端，包括：处理器、存储器、通信接口和通信总线，所述处理器、所述存储器和所述通信接口通过所述通信总线完成相互间的通信；
所述存储器用于存放至少一可执行指令，所述可执行指令使所述处理器执行上述保险理赔案件互斥信息的确定方法对应的操作。
借由上述技术方案，本申请实施例提供的技术方案至少具有下列优点：
本申请提供了一种保险理赔案件互斥信息的确定方法及装置，首先获取理赔案件中被保险人的理赔数据，然后根据预置互斥规则判断所述理赔数据中是否存在互斥信息，所述预置互斥规则用于反应所述理赔数据中的互斥关系，若存在互斥信息，则对所述互斥信息进行标记。与现有对于理赔案件中的具体理赔项目与治疗项目是否存在互斥，人工审核时容易出现漏洞，造成审核的错判、漏判，增加了理赔风险，且人工审核还浪费了大量的人力资源，降低审核的效率相比，本申请实施例通过根据反应理赔数据中的互斥关系的预置互斥规则来判断理赔数据中是否存在互斥情况，若存在进行标记，以便进一步的进行人工审核，减低工作人员的操作知识水平要求，提高审核理赔案件准确性及精度，降低理赔风险。
上述说明仅是本申请技术方案的概述，为了能够更清楚了解本申请的技术手段，而可依照说明书的内容予以实施，并且为了让本申请的上述和其它目的、特征和优点能够更明显易懂，以下特举本申请的具体实施方式。
附图说明
通过阅读下文优选实施方式的详细描述，各种其他的优点和益处对于本领域普通技术人员将变得清楚明了。附图仅用于示出优选实施方式的目的，而并不认为是对本申请的限制。而且在整个附图中，用相同的参考符号表示相同的部件。在附图中：
图1示出了本申请实施例提供的一种保险理赔案件互斥信息的确定方法流程图；
图2示出了本申请实施例提供的另一种保险理赔案件互斥信息的确定方法流程图；
图3示出了本申请实施例提供的一种保险理赔案件互斥信息的确定装置框图；
图4示出了本申请实施例提供的另一种保险理赔案件互斥信息的确定装置框图；
图5示出了本申请实施例提供的一种终端示意图。
具体实施方式
下面将参照附图更详细地描述本公开的示例性实施例。虽然附图中显示了本公开的示例性实施例，然而应当理解，可以以各种形式实现本公开而不应被这里阐述的实施例所限制。相反，提供这些实施例是为了能够更透彻地理解本公开，并且能够将本公开的范围完整的传达给本领域的技术人员。
本申请实施例提供了一种保险理赔案件互斥信息的确定方法，如图1所示，所述方法包括：
101、获取理赔案件中被保险人的理赔数据。
其中，所述被保险人是指根据生效的保险合同在保险事故发生后，享有保险金请求权的人，所述理赔案件为被保险人发生了投保产品中所规定的保险事项所产生的案件，所述理赔数据包括被保险人出现理赔时的年龄、性别、疾病、治病期间的诊疗数据，如被保险人为小王，出现理赔时的年龄为30，性别为女，疾病为子宫癌，治病期间的诊疗数据包括手术治疗为切除子宫，并进行化疗。理赔数据还划分为历史理赔案件的历史理赔数据以及当前理赔案件的当前理赔数据，历史理赔案件为相对于当前出现理赔案件之前的所有理赔案件，一般的，将本次判定理赔案件作为当前理赔数据，将相对于本次之前的所有理赔案件作为历史理赔数据。需要说明的是，若被保险人的理赔数据中没有历史理赔数据，则说明被保险人在相对于当前理赔案件发生前没有发生理赔事件，即可以针对当前理赔数据直接进行判断。另外，由于保险公司中进行投保的被保险人数量很大，所有被保险人的理赔案件在发生后都会以数据的形式录入进保险数据库中，以便在需要进行审核或核对时进行提取使用。
102、根据预置互斥规则判断所述理赔数据中是否存在互斥信息。
其中，所述预置互斥规则用于反应所述理赔数据中的互斥关系，所述互斥为相互排斥的逻辑关系，例如，被保险人的性别为男性，患有的疾病为子宫癌，对于正常的男性是不可能存在的，这种情况即为互斥。所述预置互斥规则中保存有年龄、性别、疾病、治病期间的诊疗数据之间出现的所有的互斥情况，例如，被保险人年龄为20岁，患有疾病为老年性紫癜，然而，对于35岁以下的正常人来说，不可能患有老年性紫癜，因此，年龄段在35岁以下与疾病为老年性紫癜为互斥，本申请实施例不做具体限定。另外，对于判断理赔数据中的是否互斥信息还包括当前理赔数据与历史理赔数据进行判断，例如，历史理赔数据中治病期间的诊疗数据为切除右肾，而当前理赔数据中治病期间的诊疗数据为确诊右肾结石，对于正常切除右肾的人不会出现右肾结石的病因，说明历史理赔数据与当前理赔数据中存在互斥信息。
需要说明的是，预置互斥规则可以具体包括年龄与疾病之间的互斥关系、性别与疾病之间的互斥关系、关联疾病之间的互斥关系、差异疾病之间的互斥关系、特殊人群疾病之间的互斥关系、疾病与检查类型之间的互斥关系，一般的，会预先设定具体的年龄段与哪些疾病为互斥关系，具体的性别与哪些疾病之间为互斥关系，具体的哪些疾病为关联的互斥，具体的哪些疾病为差异的互斥，具体的哪些特殊人群的疾病为互斥关系。这些互斥关系可以以数据列表形式存在于数据库中，以便体现一一对应的关系。
103、若所述理赔数据中存在互斥信息，则对所述互斥信息进行标记。
其中，为了将存在互斥信息的理赔数据及对应的理赔案件提高给审核人员进行人工审核，因此，需要对互斥信息进行标记，以便审核人员直接提取出现互斥信息的案件，从而提高审核效率。需要说明的是，若所述理赔数据中不存在互斥信息，则说明当前理赔数据为正常的理赔案件，保险公司可以进行正常的理赔。
本申请提供了一种保险理赔案件互斥信息的确定方法，与现有对于理赔案件中的具体理赔项目与治疗项目是否存在互斥，人工审核时容易出现漏洞，造成审核的错判、漏判，增加了理赔风险，且人工审核还浪费了大量的人力资源，降低审核的效率相比，本申请实施例通过根据反应理赔数据中的互斥关系的预置互斥规则来判断理赔数据中是否存在互斥情况，若存在进行标记，以便进一步的进行人工审核，减低工作人员的操作知识水平要求，提高审核理赔案件准确性及精度，降低理赔风险。
本申请实施例提供了另一种保险理赔案件互斥信息的确定方法，如图2所示，所述方法包括：
201、获取理赔案件中被保险人的理赔数据。
本步骤与图1所示的步骤102方法相同，在此不再赘述。需要说明的是，一般的，在理赔数据进行存储的过程中，不同的被保险人的理赔数据按照保单的单号进行存储，每个单号下对应这个被保险人的所有理赔数据，以便在执行获取步骤时，直接根据理赔案件中被保险人的保单单号得到理赔数据，其中，保单单号可以是主单单号，也可以是分单单号，本申请实施例不做具体限定。
202、分别解析所述理赔数据中的年龄、疾病标识码、性别以及诊疗标识码，将所述理赔数据的年龄、疾病标识码、性别以及诊疗标识码匹配至所述预置互斥规则中，并根据所述预置互斥规则中的逻辑关系确定所述理赔数据中是否存在互斥信息。
对于本申请实施例，由于在保险理赔案件中可能会使理赔案件出现互斥情况的大部分因素都是由年龄、性别、疾病、诊疗信息决定的，因此，在将理赔数据与预置互斥规则进行判断时，需要解析理赔数据中的年龄、疾病、性别以及诊疗信息，所述诊疗信息包括一次性手术诊疗项目、就诊疾病、检查项目等，所述逻辑关系用于反应所述标识码替代所述疾病后与所述年龄、性别以及诊疗信息之间的互斥情况，具体包括：年龄与疾病互斥的情况，性别与疾病互斥的情况，一次性手术后因关联疾病就诊互斥的情况，同一人因疾病就诊互斥的情况，特殊疾病人群因疾病就诊互斥的情况，疾病与检查项目互斥的情况，本申请实施例不做具体限定。通过解析理赔数据中的年龄、疾病、性别以及诊疗信息，并预置互斥规则进行匹配，从而提取出理赔数据中互斥的信息，以便进行人工审核，提高审核的准确性及效率。
其中，对于年龄与疾病互斥的情况，包括每个年龄段对应的不可能患有的疾病，一般的，会将年龄段划分为3个，分别为：年龄<16，16≤年龄<35，年龄>55，如15岁的人若患有老年性紫癜则为互斥情况。对于性别与疾病互斥的情况，包括2种情况，“男性患有女性疾病”与“女性患有男性疾病”，一般的，这种互斥的患病情况可以以对应列表形式存在，例如，疾病为盆腔腹膜和特指泌尿生殖器官的衣原体感染与男性对应，则为互斥情况。对于一次性手术后因关联疾病就诊互斥的情况，包括一次性手术后又患有手术后不可能患有的疾病，即若一次性对某个病因手术后又患有与这个病因相关的疾病，则为互斥情况，例如，一次性手术为经腹全子宫切除术，当前所患有疾病为子宫内膜结，则为互斥情况。对于同一人因疾病就诊互斥的情况，包括同一个患者在患有一种疾病后又患有与这种疾病不可能同时存在的疾病，即若同一个人患有某病后，又患有在某病情况下本不应该患有的疾病，如，被保险人的历史理赔数据中的诊疗信息为高血压性视网膜病变，而当前理赔数据中的诊疗信息为特发性低血压，则为互斥情况。对于特殊疾病人群因疾病就诊互斥的情况，包括患有特殊疾病的人又患有这种特殊疾病情况下不可能患有的疾病，即若患有特殊疾病的人群，又患有特殊情况下本部应该患有的疾病，如，历史理赔数据中的诊疗信息为腹腔妊娠，当前理赔数据中的诊疗信息为高血压性视网膜病变，则为互斥情况。对于疾病与检查项目互斥的情况，包括所做检查项目与患有疾病不相关，即若患有某疾病的同一人所做与某疾病不相关的检查，如，当前理赔数据的诊疗信息中患有疾病为乳腺癌，则记录的检查项目为视网膜检查，则为互斥情况。
需要说明的是，由于记录在数据库中的年龄、疾病、性别以及诊疗信息的对应关系及数据量很大，可以以程序代码形式将具体的年龄、疾病、性别以及诊疗信息进行存储，本申请实施例不做具体限定。另外，对于疾病种类，可以为目前世界卫生组织公布的所有疾病名称，诊疗信息中的一次性手术诊疗项目、就诊疾病、检查项目等信息，也为世界卫生组织公布的相应名称一致，本申请实施例不做具体限定。
另外，对于本申请实施例中，针对年龄、疾病、性别以及诊疗信息在判断是否与预置互斥规则匹配时，可以按照先后顺序分别判断年龄与年龄与疾病互斥的情况、性别与疾病互斥的情况、一次性手术后因关联疾病就诊互斥的情况、同一人因疾病就诊互斥的情况、特殊疾病人群因疾病就诊互斥的情况、疾病与检查项目互斥的情况的互斥情况，若其中一项存在互斥信息，则可以不进行后面的判断，直接进行标记，以便审核人员进行人工核对，加快审核效率。
对于本申请实施例，步骤202中配置预置互斥规则的方法包括：获取全部疾病的项目数据，将疾病的科目及诊疗的类型作为生成标识码的顺序依据，按照所述顺序对所述项目数据中的诊疗信息及疾病排序得到与所述诊疗信息及疾病一一对应的标识码，并将所述理赔数据中的疾病替换为对应的标识码，以及将所述理赔数据中的诊疗信息替换为对应的标识码；根据年龄与疾病互斥的情况、性别与疾病互斥的情况、一次性手术后因关联疾病就诊互斥的情况、同一人因疾病就诊互斥的情况、特殊疾病人群因疾病就诊互斥的情况、疾病与检查项目互斥的情况配置理赔数据的逻辑关系，所述逻辑关系用于反应所述标识码替代所述疾病及诊疗信息后与所述年龄、性别之间的互斥情况；将所述逻辑关系确定为预置互斥规则。其中，所述全部疾病的项目数据即为世界卫生组织公布的疾病、治疗项目、检查项目等信息，所述标识码用于唯一标识疾病、诊疗信息，以便简化疾病的匹配查找步骤。疾病的科目可以为按照不同身体部位划分的科目，例如，眼科、内科、妇科等，本申请实施例不做具体限定，诊疗的类型为治疗疾病的治疗名称及检查名称，例如，B超、CT检查、女性激素六项化验等，本申请实施例不做具体限定，所述顺序可以为将疾病按照内科、外科、内分泌循环科、妇科、儿科、骨科等作为编排疾病标识码的顺序，还可以为按照血液化验类、X射线检查类等作为编排诊疗信息标识码的顺序，本申请实施例不做具体限定。根据标识码配置理赔数据的逻辑关系包括根据存在互斥情况的逻辑将疾病标识码与年龄、性别、诊疗标识码进行多对多的对应配置，得到一个多维度的对应关系，从这个对应关系中可以清楚的查询到一个疾病的疾病标识码与年龄、性别、诊疗标识码之间存在互斥情况的关系，例如，数据库底层中存在一个标识码ICD列表，包括了D69.202为老年性紫癜的ICD、A56.100为盆腔腹膜和特指泌尿生殖器官的衣原体感染的ICD、SURG.F03117为一次性手术经腹全子宫切除术的ICD、I95.000为特发性低血压的ICD、H35.004为高血压性视网膜病变的ICD等，本申请实施例不做具体限定。通过年龄、疾病标识码、性别以及诊疗标识码之间的互斥情况的逻辑关系得到预置互斥规则，从而实现无需人为判断则可确定出不符合正常逻辑的互斥情况，增加了审核效率及准确性。
对于本申请实施例，所述根据年龄与疾病互斥的情况、性别与疾病互斥的情况、一次性手术后因关联疾病就诊互斥的情况、同一人因疾病就诊互斥的情况、特殊疾病人群因疾病就诊互斥的情况、疾病与检查项目互斥的情况配置理赔数据的逻辑关系包括：分别获取根据年龄与疾病互斥的情况、性别与疾病互斥的情况、一次性手术后因关联疾病就诊互斥的情况、同一人因疾病就诊互斥的情况、特殊疾病人群因疾病就诊互斥的情况、疾病与检查项目互斥的情况的预设对应关系，根据所述预设对应关系将所述年龄、疾病标识码、性别、就诊标识码作为向量的行及列生成具有0、1标识的多维空间向量。其中，年龄与疾病互斥的情况、性别与疾病互斥的情况、一次性手术后因关联疾病就诊互斥的情况、同一人因疾病就诊互斥的情况、特殊疾病人群因疾病就诊互斥的情况、疾病与检查项目互斥的情况的预设对应关系由技术人员进行设定，对应关系包括年龄、疾病标识码、性别以及诊疗标识码之间是否为不可能存在的具体情况，然后生成以多维映射关系的一个空间向量，即为逻辑关系，这个多维空间向量为包括1、0元素，行与列代表年龄、疾病、性别、诊疗信息、标识码，1为“互斥”，0为“不互斥”，例如，根据行向量元素的年龄为10，列向量元素的标识码为D69.202，确定向量中的互斥情况对应为1，本申请实施例不做具体限定。可以根据这个多维的空间向量对理赔数据中的年龄、疾病标识码、性别以及诊疗标识码进行查询对应的互斥情况，无需进行人工核对，提高审核效率。
203a、若所述理赔数据中存在互斥信息，则对所述互斥信息进行标记。
需要说明的是，所示互斥信息包括了互斥的年龄、疾病标识码、性别、诊疗标识码的具体内容，为了以便工作人员进行人工审核。标记的形式可以为将互斥信息标记为阳性，也可以为标记为红色等，相对的不互斥的信息可以不进行标记，也可以标记为阴性或绿色等，本申请实施例不做具体限定。另外，对于上述出现互斥情况的理赔数据，可以针对出现一个互斥信息时进行标记，其他数据不再进行判断，还可以判断所有的互斥信息并标记出来，本申请实施例不做具体限定。对于本申请实施例，与步骤203a并列的步骤203b、若所述理赔数据中不存在互斥信息，则获取所述被保险人的历史保单信息。
对于本申请实施例，当理赔数据中的年龄、疾病、性别以及诊疗信息中不存在互斥信息，为了进一步验证被保险人的理赔风险是否过高，需要对被保险人的历史保单信息进行解析，从而确定历史保单信息中是否存在互斥的可能性。一般的，被保险人的历史保单信息可以为保单信息或分单信息，具体包括连带关系、黑名单信息、联系信息等内容，本申请实施例不做具体限定。
对于本申请实施例，步骤203b之后的步骤204、分别判断所述历史保单信息中的主被连带关系、联系信息是否存在互斥情况，若存在互斥情况，则进行标记以及展示，若不存在互斥情况，则判断所述历史保单信息是否记录在预置黑名单中，若是，则进行标记以及展示。其中，所述主被连带关系包括根据客户单号、证件号检索主被历史保单的连带信息，即连带信息为投保人、被保人、主单、分单、投保人与被保人之间的关系，如配偶、子女、父母等，本申请不做具体限定，所述联系信息包括联系电话、联系邮箱，所述预置黑名单包括就诊医院信息、投保人信息、被保人信息的黑名单，黑名单的添加可以为不按期缴费、理赔数额超过预定值或其他被列为黑名单的情况，本申请实施例不做具体限定。需要说明的是，对于主被连带关系的互斥情况为若连带信息的姓名、证件号与历史记录不一致，则为互斥情况，对于联系信息的互斥情况包括多人使用相同电话号码或邮箱，即若分单号不一致，系统内存储的历史保单信息中多人共同一个电话或邮箱，则为互斥情况，如2个分单号对应的电话为相同的电话，本申请实施例不做具体限定，所述预置黑名单的互斥情况为保单信息中的被保险人、投保人、就诊医院等信息存在于预置黑名单中即为互斥情况，预置黑名单医院可以为出现医疗事故的医院，或者级别较低的医院，预置黑名单单位为被保险人不按期缴费投保的人或单位，本申请实施例不做具体限定。通过对主被连带关系、联系信息以及预置黑名单中的信息进行判别，进一步的精确理赔案件在历史保单信息中是否存在互斥的情况，扩大排查范围，从而提高理赔案件的审查力度，降低理赔案件的理赔风险。
对于本申请实施例，步骤203a与204之后的步骤205、发送预警信息，并将带有标记的互斥信息对应的理赔案件进行展示。为了向工作人员及时有效的提供互斥信息对应的理赔数据，便于工作人员审核出现互斥信息的理赔案件，因此需要发送预警信息。预警信息可以为声音提示信息以及对话框提示信息等，以便用户进行人工审核，本申请实施例不做具体限定。
本申请提供了另一种保险理赔案件互斥信息的确定方法，本申请实施例通过解析理赔数据中的年龄、疾病标识码、性别以及诊疗标识码与预置互斥规则中的逻辑关系进行查找匹配，确定是否存在互斥情况，若不存在，进一步的判断历史保单信息中是否存在主被连带关系、联系信息以及预置黑名单的互斥情况，若存在则进行标记，以便进行进一步地的人工审核，实现简化人工审核的繁杂步骤，减低工作人员的操作知识水平要求，提高时效性，较少理赔案件的审核时间，提高审核理赔案件准确性及精度，降低理赔风险。
进一步的，作为对上述图1所示方法的实现，本申请实施例提供了一种保险理赔案件互斥信息的确定装置，如图3所示，该装置包括：第一获取单元31、第一判断单元32、标记单元33。
第一获取单元31，用于获取理赔案件中被保险人的理赔数据；所述第一获取单元31为保险理赔案件互斥信息的确定装置执行获取理赔案件中被保险人的理赔数据的程序模块。第一判断单元32，用于根据预置互斥规则判断所述理赔数据中是否存在互斥信息，所述预置互斥规则用于反应所述理赔数据中的互斥关系；所述第一判断单元32为保险理赔案件互斥信息的确定装置执行根据预置互斥规则判断所述理赔数据中是否存在互斥信息的程序模块。标记单元33，用于若存在互斥信息，则对所述互斥信息进行标记。所述标记单元33为保险理赔案件互斥信息的确定装置执行对所述互斥信息进行标记的程序模块。
本申请提供了一种保险理赔案件互斥信息的确定装置，与现有对于理赔案件中的具体理赔项目与治疗项目是否存在互斥，人工审核时容易出现漏洞，造成审核的错判、漏判，增加了理赔风险，且人工审核还浪费了大量的人力资源，降低审核的效率相比，本申请实施例通过根据反应理赔数据中的互斥关系的预置互斥规则来判断理赔数据中是否存在互斥情况，若存在进行标记，以便进一步的进行人工审核，减低工作人员的操作知识水平要求，提高审核理赔案件准确性及精度，降低理赔风险。
进一步的，作为对上述图2所示方法的实现，本申请实施例提供了另一种保险理赔案件互斥信息的确定装置，如图4所示，该装置包括：第一获取单元41、第一判断单元42、标记单元43、第二获取单元44、第二判断单元45、发送单元46。
第一获取单元41，用于获取理赔案件中被保险人的理赔数据；第一判断单元42，用于根据预置互斥规则判断所述理赔数据中是否存在互斥信息，所述预置互斥规则用于反应所述理赔数据中的互斥关系；标记单元43，用于若存在互斥信息，则对所述互斥信息进行标记。
进一步地，所述装置还包括：
第二获取单元44，用于若所述理赔数据中不存在互斥信息，则获取所述被保险人的历史保单信息；第二判断单元45，用于分别判断所述历史保单信息中的主被连带关系、联系信息是否存在互斥情况，若存在互斥情况，则进行标记以及展示，若不存在互斥情况，则判断所述历史保单信息是否记录在预置黑名单中，若是，则进行标记以及展示。
具体的，所述第一判断单元42包括：获取模块4201，用于获取全部疾病的项目数据，将疾病的科目及诊疗的类型作为生成标识码的顺序依据，按照所述顺序对所述项目数据中的诊疗信息及疾病排序得到与所述诊疗信息及疾病一一对应的标识码，并将所述理赔数据中的疾病替换为对应的标识码，以及将所述理赔数据中的诊疗信息替换为对应的标识码；配置模块4202，用于根据年龄与疾病互斥的情况、性别与疾病互斥的情况、一次性手术后因关联疾病就诊互斥的情况、同一人因疾病就诊互斥的情况、特殊疾病人群因疾病就诊互斥的情况、疾病与检查项目互斥的情况配置理赔数据的逻辑关系，所述逻辑关系用于反应所述标识码替代所述疾病及诊疗信息后与所述年龄、性别之间的互斥情况；确定模块4203，用于将所述逻辑关系确定为预置互斥规则。
具体的，所述第一判断单元42，具体用于分别解析所述理赔数据中的年龄、疾病标识码、性别以及诊疗标识码，将所述理赔数据的年龄、疾病标识码、性别以及诊疗标识码匹配至所述预置互斥规则中，并根据所述预置互斥规则中的逻辑关系确定所述理赔数据中是否存在互斥信息。
具体的，所述配置模块4202，具体用于分别获取根据年龄与疾病互斥的情况、性别与疾病互斥的情况、一次性手术后因关联疾病就诊互斥的情况、同一人因疾病就诊互斥的情况、特殊疾病人群因疾病就诊互斥的情况、疾病与检查项目互斥的情况的预设对应关系，根据所述预设对应关系将所述年龄、疾病标识码、性别、就诊标识码作为向量的行及列生成具有0、1标识的多维空间向量。
进一步地，所述装置还包括：发送单元46，用于发送预警信息，并将带有标记的互斥信息对应的理赔案件进行展示，以便用户进行人工审核。
本申请提供了另一种保险理赔案件互斥信息的确定装置，本申请实施例通过解析理赔数据中的年龄、疾病标识码、性别以及诊疗标识码与预置互斥规则中的逻辑关系进行查找匹配，确定是否存在互斥情况，若不存在，进一步的判断历史保单信息中是否存在主被连带关系、联系信息以及预置黑名单的互斥情况，若存在则进行标记，以便进行进一步地的人工审核，实现简化人工审核的繁杂步骤，减低工作人员的操作知识水平要求，提高时效性，较少理赔案件的审核时间，提高审核理赔案件准确性及精度，降低理赔风险。
根据本申请一个实施例提供了一种存储介质，所述存储介质存储有至少一可执行指令，该计算机可执行指令可执行上述任意方法实施例中的保险理赔案件互斥信息的确定方法。图5示出了根据本申请一个实施例提供的一种终端的结构示意图，本申请具体实施例并不对终端的具体实现做限定。如图5所示，该终端可以包括：处理器(processor)502、通信接口(Communications Interface)504、存储器(memory)506、以及通信总线508。
其中：处理器502、通信接口504、以及存储器506通过通信总线508完成相互间的通信。通信接口504，用于与其它设备比如客户端或其它服务器等的网元通信。处理器502，用于执行程序510，具体可以执行上述保险理赔案件互斥信息的确定方法实施例中的相关步骤。具体地，程序510可以包括程序代码，该程序代码包括计算机操作指令。处理器502可能是中央处理器CPU，或者是特定集成电路ASIC（Application Specific Integrated Circuit），或者是被配置成实施本申请实施例的一个或多个集成电路。终端包括的一个或多个处理器，可以是同一类型的处理器，如一个或多个CPU；也可以是不同类型的处理器，如一个或多个CPU以及一个或多个ASIC。存储器506，用于存放程序510。存储器506可能包含高速RAM存储器，也可能还包括非易失性存储器（non-volatile memory），例如至少一个磁盘存储器。程序510具体可以用于使得处理器502执行以下操作：
获取理赔案件中被保险人的理赔数据；根据预置互斥规则判断所述理赔数据中是否存在互斥信息，所述预置互斥规则用于反应所述理赔数据中的互斥关系；若存在互斥信息，则对所述互斥信息进行标记。
在此提供的算法和显示不与任何特定计算机、虚拟系统或者其它设备固有相关。各种通用系统也可以与基于在此的示教一起使用。根据上面的描述，构造这类系统所要求的结构是显而易见的。此外，本申请也不针对任何特定编程语言。应当明白，可以利用各种编程语言实现在此描述的本申请的内容，并且上面对特定语言所做的描述是为了披露本申请的最佳实施方式。在此处所提供的说明书中，说明了大量具体细节。然而，能够理解，本申请的实施例可以在没有这些具体细节的情况下实践。在一些实例中，并未详细示出公知的方法、结构和技术，以便不模糊对本说明书的理解。
类似地，应当理解，为了精简本公开并帮助理解各个发明方面中的一个或多个，在上面对本申请的示例性实施例的描述中，本申请的各个特征有时被一起分组到单个实施例、图、或者对其的描述中。然而，并不应将该公开的方法解释成反映如下意图：即所要求保护的本申请要求比在每个权利要求中所明确记载的特征更多的特征。更确切地说，如下面的权利要求书所反映的那样，发明方面在于少于前面公开的单个实施例的所有特征。因此，遵循具体实施方式的权利要求书由此明确地并入该具体实施方式，其中每个权利要求本身都作为本申请的单独实施例。
本领域那些技术人员可以理解，可以对实施例中的设备中的模块进行自适应性地改变并且把它们设置在与该实施例不同的一个或多个设备中。可以把实施例中的模块或单元或组件组合成一个模块或单元或组件，以及此外可以把它们分成多个子模块或子单元或子组件。除了这样的特征和/或过程或者单元中的至少一些是相互排斥之外，可以采用任何组合对本说明书（包括伴随的权利要求、摘要和附图）中公开的所有特征以及如此公开的任何方法或者设备的所有过程或单元进行组合。除非另外明确陈述，本说明书（包括伴随的权利要求、摘要和附图）中公开的每个特征可以由提供相同、等同或相似目的的替代特征来代替。
此外，本领域的技术人员能够理解，尽管在此所述的一些实施例包括其它实施例中所包括的某些特征而不是其它特征，但是不同实施例的特征的组合意味着处于本申请的范围之内并且形成不同的实施例。例如，在下面的权利要求书中，所要求保护的实施例的任意之一都可以以任意的组合方式来使用。
本申请的各个部件实施例可以以硬件实现，或者以在一个或者多个处理器上运行的软件模块实现，或者以它们的组合实现。本领域的技术人员应当理解，可以在实践中使用微处理器或者数字信号处理器（DSP）来实现根据本申请实施例的保险理赔案件互斥信息的确定方法及装置中的一些或者全部部件的一些或者全部功能。本申请还可以实现为用于执行这里所描述的方法的一部分或者全部的设备或者装置程序（例如，计算机程序和计算机程序产品）。这样的实现本申请的程序可以存储在计算机可读介质上，或者可以具有一个或者多个信号的形式。这样的信号可以从因特网网站上下载得到，或者在载体信号上提供，或者以任何其他形式提供。
应该注意的是上述实施例对本申请进行说明而不是对本申请进行限制，并且本领域技术人员在不脱离所附权利要求的范围的情况下可设计出替换实施例。在权利要求中，不应将位于括号之间的任何参考符号构造成对权利要求的限制。单词“包含”不排除存在未列在权利要求中的元件或步骤。位于元件之前的单词“一”或“一个”不排除存在多个这样的元件。本申请可以借助于包括有若干不同元件的硬件以及借助于适当编程的计算机来实现。在列举了若干装置的单元权利要求中，这些装置中的若干个可以是通过同一个硬件项来具体体现。单词第一、第二、以及第三等的使用不表示任何顺序。可将这些单词解释为名称。

Claims (24)

  1. 一种保险理赔案件互斥信息的确定方法，其特征在于，包括：
    获取理赔案件中被保险人的理赔数据；
    根据预置互斥规则判断所述理赔数据中是否存在互斥信息，所述预置互斥规则用于反应所述理赔数据中的互斥关系；
    若存在互斥信息，则对所述互斥信息进行标记。
  2. 根据权利要求1所述的方法，其特征在于，所述根据预置互斥规则判断所述理赔数据中是否存在互斥信息之后，所述方法还包括：
    若所述理赔数据中不存在互斥信息，则获取所述被保险人的历史保单信息；
    分别判断所述历史保单信息中的主被连带关系、联系信息是否存在互斥情况，若存在互斥情况，则进行标记以及展示，若不存在互斥情况，则判断所述历史保单信息是否记录在预置黑名单中，若是，则进行标记以及展示。
  3. 根据权利要求2所述的方法，其特征在于，所述方法中预置互斥规则的配置方法包括：
    获取全部疾病的项目数据，将疾病的科目及诊疗的类型作为生成标识码的顺序依据，按照所述顺序对所述项目数据中的诊疗信息及疾病排序得到与所述诊疗信息及疾病一一对应的标识码，并将所述理赔数据中的疾病替换为对应的标识码，以及将所述理赔数据中的诊疗信息替换为对应的标识码；
    根据年龄与疾病互斥的情况、性别与疾病互斥的情况、一次性手术后因关联疾病就诊互斥的情况、同一人因疾病就诊互斥的情况、特殊疾病人群因疾病就诊互斥的情况、疾病与检查项目互斥的情况配置理赔数据的逻辑关系，所述逻辑关系用于反应所述标识码替代所述疾病及诊疗信息后与所述年龄、性别之间的互斥情况；
    将所述逻辑关系确定为预置互斥规则。
  4. 根据权利要求2所述的方法，其特征在于，所述根据预置互斥规则判断所述理赔数据中是否存在互斥信息包括：
    分别解析所述理赔数据中的年龄、疾病标识码、性别以及诊疗标识码，将所述理赔数据的年龄、疾病标识码、性别以及诊疗标识码匹配至所述预置互斥规则中，并根据所述预置互斥规则中的逻辑关系确定所述理赔数据中是否存在互斥信息。
  5. 根据权利要求4所述的方法，其特征在于，所述根据年龄与疾病互斥的情况、性别与疾病互斥的情况、一次性手术后因关联疾病就诊互斥的情况、同一人因疾病就诊互斥的情况、特殊疾病人群因疾病就诊互斥的情况、疾病与检查项目互斥的情况配置理赔数据的逻辑关系包括：
    分别获取根据年龄与疾病互斥的情况、性别与疾病互斥的情况、一次性手术后因关联疾病就诊互斥的情况、同一人因疾病就诊互斥的情况、特殊疾病人群因疾病就诊互斥的情况、疾病与检查项目互斥的情况的预设对应关系，根据所述预设对应关系将所述年龄、疾病标识码、性别、就诊标识码作为向量的行及列生成具有0、1标识的多维空间向量。
  6. 根据权利要求1所述的方法，其特征在于，所述若存在互斥信息，则对所述互斥信息进行标记之后，所述方法还包括：
    发送预警信息，并将带有标记的互斥信息对应的理赔案件进行展示，以便用户进行人工审核。
  7. 一种保险理赔案件互斥信息的确定装置，其特征在于，包括：
    第一获取单元，用于获取理赔案件中被保险人的理赔数据；
    第一判断单元，用于根据预置互斥规则判断所述理赔数据中是否存在互斥信息，所述预置互斥规则用于反应所述理赔数据中的互斥关系；
    标记单元，用于若存在互斥信息，则对所述互斥信息进行标记。
  8. 根据权利要求7所述的装置，其特征在于，所述装置还包括：
    第二获取单元，用于若所述理赔数据中不存在互斥信息，则获取所述被保险人的历史保单信息；
    第二判断单元，用于分别判断所述历史保单信息中的主被连带关系、联系信息是否存在互斥情况，若存在互斥情况，则进行标记以及展示，若不存在互斥情况，则判断所述历史保单信息是否记录在预置黑名单中，若是，则进行标记以及展示。
  9. 根据权利要求8所述的装置，其特征在于，所述第一判断单元包括：
    获取模块，用于获取全部疾病的项目数据，将疾病的科目及诊疗的类型作为生成标识码的顺序依据，按照所述顺序对所述项目数据中的诊疗信息及疾病排序得到与所述诊疗信息及疾病一一对应的标识码，并将所述理赔数据中的疾病替换为对应的标识码，以及将所述理赔数据中的诊疗信息替换为对应的标识码；
    配置模块，用于根据年龄与疾病互斥的情况、性别与疾病互斥的情况、一次性手术后因关联疾病就诊互斥的情况、同一人因疾病就诊互斥的情况、特殊疾病人群因疾病就诊互斥的情况、疾病与检查项目互斥的情况配置理赔数据的逻辑关系，所述逻辑关系用于反应所述标识码替代所述疾病及诊疗信息后与所述年龄、性别之间的互斥情况；
    确定模块，用于将所述逻辑关系确定为预置互斥规则。
  10. 根据权利要求8所述的装置，其特征在于，所述第一判断单元，具体用于分别解析所述理赔数据中的年龄、疾病标识码、性别以及诊疗标识码，将所述理赔数据的年龄、疾病标识码、性别以及诊疗标识码匹配至所述预置互斥规则中，并根据所述预置互斥规则中的逻辑关系确定所述理赔数据中是否存在互斥信息。
  11. 根据权利要求10所述的装置，其特征在于，所述配置模块，具体用于分别获取根据年龄与疾病互斥的情况、性别与疾病互斥的情况、一次性手术后因关联疾病就诊互斥的情况、同一人因疾病就诊互斥的情况、特殊疾病人群因疾病就诊互斥的情况、疾病与检查项目互斥的情况的预设对应关系，根据所述预设对应关系将所述年龄、疾病标识码、性别、就诊标识码作为向量的行及列生成具有0、1标识的多维空间向量。
  12. 根据权利要求7所述的装置，其特征在于，所述装置还包括：
    发送单元，用于发送预警信息，并将带有标记的互斥信息对应的理赔案件进行展示，以便用户进行人工审核。
  13. 一种存储介质，其上存储有计算机程序，其特征在于，所述程序被处理器执行时实现保险理赔案件互斥信息的确定方法，包括：
    获取理赔案件中被保险人的理赔数据；根据预置互斥规则判断所述理赔数据中是否存在互斥信息，所述预置互斥规则用于反应所述理赔数据中的互斥关系；若存在互斥信息，则对所述互斥信息进行标记。
  14. 根据权利要求13所述的存储介质，其特征在于，所述根据预置互斥规则判断所述理赔数据中是否存在互斥信息之后，所述方法还包括：
    若所述理赔数据中不存在互斥信息，则获取所述被保险人的历史保单信息；分别判断所述历史保单信息中的主被连带关系、联系信息是否存在互斥情况，若存在互斥情况，则进行标记以及展示，若不存在互斥情况，则判断所述历史保单信息是否记录在预置黑名单中，若是，则进行标记以及展示。
  15. 根据权利要求14所述的存储介质，其特征在于，所述方法中预置互斥规则的配置方法包括：
    获取全部疾病的项目数据，将疾病的科目及诊疗的类型作为生成标识码的顺序依据，按照所述顺序对所述项目数据中的诊疗信息及疾病排序得到与所述诊疗信息及疾病一一对应的标识码，并将所述理赔数据中的疾病替换为对应的标识码，以及将所述理赔数据中的诊疗信息替换为对应的标识码；根据年龄与疾病互斥的情况、性别与疾病互斥的情况、一次性手术后因关联疾病就诊互斥的情况、同一人因疾病就诊互斥的情况、特殊疾病人群因疾病就诊互斥的情况、疾病与检查项目互斥的情况配置理赔数据的逻辑关系，所述逻辑关系用于反应所述标识码替代所述疾病及诊疗信息后与所述年龄、性别之间的互斥情况；将所述逻辑关系确定为预置互斥规则。
  16. 根据权利要求14所述的存储介质，其特征在于，所述根据预置互斥规则判断所述理赔数据中是否存在互斥信息包括：
    分别解析所述理赔数据中的年龄、疾病标识码、性别以及诊疗标识码，将所述理赔数据的年龄、疾病标识码、性别以及诊疗标识码匹配至所述预置互斥规则中，并根据所述预置互斥规则中的逻辑关系确定所述理赔数据中是否存在互斥信息。
  17. 根据权利要求16所述的存储介质，其特征在于，所述根据年龄与疾病互斥的情况、性别与疾病互斥的情况、一次性手术后因关联疾病就诊互斥的情况、同一人因疾病就诊互斥的情况、特殊疾病人群因疾病就诊互斥的情况、疾病与检查项目互斥的情况配置理赔数据的逻辑关系包括：
    分别获取根据年龄与疾病互斥的情况、性别与疾病互斥的情况、一次性手术后因关联疾病就诊互斥的情况、同一人因疾病就诊互斥的情况、特殊疾病人群因疾病就诊互斥的情况、疾病与检查项目互斥的情况的预设对应关系，根据所述预设对应关系将所述年龄、疾病标识码、性别、就诊标识码作为向量的行及列生成具有0、1标识的多维空间向量。
  18. 根据权利要求13所述的存储介质，其特征在于，所述若存在互斥信息，则对所述互斥信息进行标记之后，所述方法还包括：
    发送预警信息，并将带有标记的互斥信息对应的理赔案件进行展示，以便用户进行人工审核。
  19. 一种终端，其特征在于，所述装置包括存储介质和处理器，所述存储介质，用于存储计算机程序；
    所述处理器，用于执行所述计算机程序以实现保险理赔案件互斥信息的确定方法，包括：获取理赔案件中被保险人的理赔数据；根据预置互斥规则判断所述理赔数据中是否存在互斥信息，所述预置互斥规则用于反应所述理赔数据中的互斥关系；若存在互斥信息，则对所述互斥信息进行标记。
  20. 根据权利要求19所述的终端，其特征在于，所述程序被处理器执行时实现所述根据预置互斥规则判断所述理赔数据中是否存在互斥信息之后，所述方法还包括：
    若所述理赔数据中不存在互斥信息，则获取所述被保险人的历史保单信息；分别判断所述历史保单信息中的主被连带关系、联系信息是否存在互斥情况，若存在互斥情况，则进行标记以及展示，若不存在互斥情况，则判断所述历史保单信息是否记录在预置黑名单中，若是，则进行标记以及展示。
  21. 根据权利要求20所述的终端，其特征在于，所述程序被处理器执行时实现所述方法中预置互斥规则的配置方法包括：
    获取全部疾病的项目数据，将疾病的科目及诊疗的类型作为生成标识码的顺序依据，按照所述顺序对所述项目数据中的诊疗信息及疾病排序得到与所述诊疗信息及疾病一一对应的标识码，并将所述理赔数据中的疾病替换为对应的标识码，以及将所述理赔数据中的诊疗信息替换为对应的标识码；根据年龄与疾病互斥的情况、性别与疾病互斥的情况、一次性手术后因关联疾病就诊互斥的情况、同一人因疾病就诊互斥的情况、特殊疾病人群因疾病就诊互斥的情况、疾病与检查项目互斥的情况配置理赔数据的逻辑关系，所述逻辑关系用于反应所述标识码替代所述疾病及诊疗信息后与所述年龄、性别之间的互斥情况；将所述逻辑关系确定为预置互斥规则。
  22. 根据权利要求20所述的终端，其特征在于，所述程序被处理器执行时实现所述根据预置互斥规则判断所述理赔数据中是否存在互斥信息包括：
    分别解析所述理赔数据中的年龄、疾病标识码、性别以及诊疗标识码，将所述理赔数据的年龄、疾病标识码、性别以及诊疗标识码匹配至所述预置互斥规则中，并根据所述预置互斥规则中的逻辑关系确定所述理赔数据中是否存在互斥信息。
  23. 根据权利要求22所述的终端，其特征在于，所述程序被处理器执行时实现所述根据年龄与疾病互斥的情况、性别与疾病互斥的情况、一次性手术后因关联疾病就诊互斥的情况、同一人因疾病就诊互斥的情况、特殊疾病人群因疾病就诊互斥的情况、疾病与检查项目互斥的情况配置理赔数据的逻辑关系包括：
    分别获取根据年龄与疾病互斥的情况、性别与疾病互斥的情况、一次性手术后因关联疾病就诊互斥的情况、同一人因疾病就诊互斥的情况、特殊疾病人群因疾病就诊互斥的情况、疾病与检查项目互斥的情况的预设对应关系，根据所述预设对应关系将所述年龄、疾病标识码、性别、就诊标识码作为向量的行及列生成具有0、1标识的多维空间向量。
  24. 根据权利要求19所述的终端，其特征在于，所述程序被处理器执行时实现所述若存在互斥信息，则对所述互斥信息进行标记之后，所述方法还包括：
    发送预警信息，并将带有标记的互斥信息对应的理赔案件进行展示，以便用户进行人工审核。
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