WO2020108048A1

WO2020108048A1 - Claim settlement processing method and apparatus

Info

Publication number: WO2020108048A1
Application number: PCT/CN2019/107668
Authority: WO
Inventors: 方雪琼
Original assignee: 阿里巴巴集团控股有限公司
Priority date: 2018-11-27
Filing date: 2019-09-25
Publication date: 2020-06-04
Also published as: CN110047007A; TW202020791A; TWI729474B

Abstract

A claim settlement processing method and apparatus. The method comprises: acquiring claim settlement data in a claim application (S101); acquiring, according to a policy identifier, a claim settling rule corresponding to policy information of a policy to be settled (S102a); acquiring credibility data of a claimant user according to a user identifier (S102b); determining, according to a preset corresponding relationship between the claim settling rule and the rule features, a plurality of rule features to be extracted, and extracting the rule features from claim evidence (S103a); extracting a plurality of preset credibility features from the credibility data (S103b); inputting the extracted features into a pre-trained claim examination model and determining, according to the output result of the model, whether the claim is successful (S104).

Description

Claim processing method and device

Technical field

The embodiments of the present specification relate to the field of Internet application technologies, and in particular, to a method and apparatus for processing claims.

Background technique

Insurance can enjoy financial and personal protection by paying the prescribed premium. With the economic development of society and the improvement of people's awareness of insurance, there is an increasing demand for insurance business. When users need to settle claims, in the traditional claims process, the personnel of the insurance company usually handle the acceptance, investigation and review of the claims. Therefore, the traditional process generally requires the communication and cooperation of personnel from multiple departments, and the claim process is long. , Inefficient, and prone to errors caused by human factors.

Based on the existing technology, a more efficient claims processing solution is needed.

Summary of the invention

In response to the above technical problems, the embodiments of this specification provide a method and device for processing claims, and the technical solutions are as follows:

A method for processing claims, the method includes:

Obtain the claim data in the claim application, the claim data at least includes: policy identification, user identification and proof of claim;

According to the policy identification, obtain a claim rule corresponding to the policy information of the insurance policy to be claimed; and, according to the user identification, obtain credit data of the claim user;

Determine a number of rule features to be extracted according to the preset correspondence relationship between the claim rules and rule features, and extract the rule features from the claim certificate; and, extract a preset number of credits from the credit data feature;

Input the extracted features into a pre-trained claim review model, and determine whether the claim application is passed according to the output of the model; wherein, the method for obtaining the output result according to the input features includes: calculating the claims according to the input rule features Proof of compliance with the claims rules; based on the entered credit characteristics, it is calculated whether the claims user meets the preset credit requirements and/or whether the fraud risk reaches the preset threshold.

A claims processing device, the device includes:

The data obtaining module is used to obtain the claim data in the claim application. The claim data includes at least: the policy identification, the user identification, and the proof of claim; and, according to the policy identification, obtain the claim rules corresponding to the policy information of the claim insurance policy; And, according to the user identification, obtain credit data of the claiming user;

The input module is used to determine several rule features to be extracted based on the preset correspondence between the claim rules and rule features, and extract the rule features from the claim certificate; and, extract from the credit data Several preset credit characteristics;

The output module is used to input the extracted features into the pre-trained claims review model, and determine whether the claim application is passed according to the output results of the model; the device that obtains the output results based on the input features includes: according to the input rule features , Calculate whether the claim certificate complies with the claim rules; based on the input credit characteristics, calculate whether the claim user meets the preset credit requirements and/or whether the fraud risk reaches the preset threshold.

The technical solution provided by the embodiment of this specification can automatically check whether the claim is approved according to the claim data in the user's claim request, combined with the user's credit data and claim rules, thereby saving manpower, shortening the process, and improving the processing of the claim business effectiveness.

It should be understood that the above general description and the following detailed description are only exemplary and explanatory, and cannot limit the embodiments of the present specification.

In addition, any of the embodiments of the present specification does not need to achieve all the above-mentioned effects.

BRIEF DESCRIPTION

In order to more clearly explain the embodiments of the specification or the technical solutions in the prior art, the following will briefly introduce the drawings required in the embodiments or the description of the prior art. Obviously, the drawings in the following description are only These are some of the embodiments described in the embodiments of this specification, and those of ordinary skill in the art can also obtain other drawings based on these drawings.

FIG. 1 is a schematic flowchart of a method for processing claims in accordance with an embodiment of the present specification;

2 is a schematic flowchart of an order insurance claim processing method according to an embodiment of this specification;

3 is a schematic structural diagram of a claims processing device according to an embodiment of the present specification;

FIG. 4 is another schematic structural diagram of the claims processing device of the embodiment of the present specification;

FIG. 5 is a schematic structural diagram of a device for configuring an apparatus of an embodiment of this specification.

detailed description

In order to enable those skilled in the art to better understand the technical solutions in the embodiments of the present specification, the technical solutions in the embodiments of the present specification will be described in detail in conjunction with the drawings in the embodiments of the present specification. Obviously, the described implementation Examples are only a part of the embodiments of this specification, but not all the embodiments. Based on the embodiments in this specification, all other embodiments obtained by those of ordinary skill in the art should fall within the scope of protection.

In response to the problems of the prior art, the embodiments of the present specification provide a method for processing claims, as shown in FIG. 1, the method may include the following steps:

S101. Obtain claim data in a claim application. The claim data includes at least: a policy identification, a user identification, and a proof of claim;

This manual can be applied to most of the existing insurance types, such as health insurance for medical reimbursement, etc., and scene insurance such as order insurance and freight insurance. Users can pass the corresponding insurance when the insurance may be settled. The platform initiates claims, and the claims application referred to in S101 can refer to claims initiated directly by the user, or it can refer to claims initiated by the user or other operations, which are generated after the corresponding process (such as auto insurance requires on-site nuclear damage) The claims application is not limited in the embodiment of this specification.

S102a, according to the policy identifier, obtain a claim rule corresponding to the policy information of the claim policy;

S102b: Obtain the credit data of the claiming user according to the user identification;

The claim rules corresponding to the policy information referred to here may include the general rules corresponding to the type of insurance that the policy belongs to, for example, it may be the range of scenarios where the type of insurance can be settled, such as only the outpatient expenses can be settled; it can also be the type of insurance The maximum amount of money that can be claimed each year is 10,000 yuan; and so on. In addition, the claim rules can also include customized rules determined based on the policy information. For example, in health insurance, some special protection limits can be set according to the policy information, the age of the insured at the time of insurance and the disease, etc.; The historical payment of the policy; etc. A person skilled in the art can set the specific clause content of the compensation rules corresponding to the policy information according to actual needs, which is not limited in the embodiments of this specification.

In addition, the embodiment of the present specification does not limit the obtained credit data of the claims user. For example, it can be the user's credit points in an insurance institution or claim platform, or the user's credit points in other institutions can be obtained; for another example, it can be the user's historical claim record or historical behavior record in an insurance institution or claim platform , Such as whether there is fraudulent insurance behavior, whether to pay premiums in time, etc.; of course, the credit data may include one or more data obtained from one or more routes, and the data may have different forms, such as It is a score form, a feature description form, etc., and the embodiments of this specification are not limited.

S103a: Determine a number of rule features to be extracted according to the preset correspondence between the claim rules and rule features, and extract the rule features from the claim certificate;

S103b: Extract preset credit features from the credit data;

As mentioned earlier, different types of insurance and even different policy information may have different rules for corresponding claims. Therefore, when extracting rule features from a proof of claim, you can set different rule features to be extracted for different claim rules.

In one example, if the claim rule stipulates a range of scenarios that can be settled, the corresponding rule feature may be a scene feature. For example, the scope of the claims scenarios specified in the claims rules are: outpatient expenses other than dental and medical cosmetics, and the claim certificate can be a billing document issued by the hospital, so that the outpatient/inpatient, medical department can be extracted from the claim certificate , Check project and other scene characteristics.

In another example, taking car insurance as an example, if damages to different positions of the vehicle are specified in the claim rules, different claim amount ranges are specified, then the corresponding rule feature may be the feature of the injury location, and the claim certificate may be from a different position of the vehicle Photos, so that the damaged parts can be extracted from the proof of claim.

It can be understood that the embodiments of this specification do not need to limit the number and specific contents of the rule features and credit features, and those skilled in the art can flexibly set them according to actual needs.

S104, input the extracted features into a pre-trained claims review model, and determine whether the claim application is passed according to the output results of the model; wherein, the method for obtaining the output results based on the input features includes: calculating the Whether the claim proof meets the claim rules; based on the input credit characteristics, calculate whether the claim user meets the preset credit requirements and/or whether the fraud risk reaches the preset threshold.

In the solution of the embodiment of the present specification, through the pre-trained claims review model, claims claims can be reviewed from three dimensions: claim rules, user credit and fraud risk.

The review dimension of the claim rules still takes the above-mentioned rule features as the scene features as an example. By extracting the scene features such as outpatient/hospitalization, consultation department, and inspection items from the claim certificate, it is judged whether they meet the claims rules. Provisions for outpatient costs other than medical and cosmetic categories.

The user's credit review dimension, for example, based on the extracted credit features, based on the preset weights, the user's credit score can be calculated by a weighting algorithm, and compared with the threshold in the preset credit requirements to determine the claim Whether the user meets the preset credit requirements.

The fraud risk review dimension, for example, the obtained credit data of the claims user may include the user's historical IP address, and the corresponding credit feature is the IP feature. Based on the IP feature, calculate whether the claimant's IP address changes frequently, and if so, it exists The risk of certain gangs committing crimes and defrauding insurance; for example, in scenarios insurance such as freight insurance, there may be cases where buyers and sellers cooperate to defraud freight insurance premiums, and the obtained credit data of the claims user (ie, buyer) In it, it can include the user's historical transaction records, and the corresponding credit characteristics are transaction characteristics. Based on the transaction characteristics, it is calculated whether the buyer frequently trades with the seller. If so, there is a certain risk of fraud and fraud; etc. All kinds of situations where there is a certain risk of fraud and fraud insurance can correspond to a certain score, and the fraud risk value of the claim application is obtained based on weighting and other operations, so that the fraud risk dimension is reviewed by whether the preset threshold is reached.

It is understandable that in order to ensure the comprehensiveness of the review, the user credit dimension and the fraud risk dimension can be jointly applied to the claims review model, but generally the users with better credit have lower fraud risks, so the two can also be applied separately The claim review model is not limited in the embodiments of this specification, and those skilled in the art can set it according to actual needs.

Of course, the claims auditing model used in this scheme does not necessarily have the correct auditing results predicted, and as the time or social environment changes, the adaptability of the model to the applied scenario will also change. Situation, in a specific implementation of this specification, the claims review model used can also be used in the process of reviewing claims applications, through the review of each claim application that has been reviewed, to further optimize and update, thereby improving prediction Accuracy.

Specifically, for each claim application that has been reviewed, the number of claim applications that have an error in the review result may be determined, and the prediction accuracy rate of the claim review model may be calculated according to the number.

For example, if the user does not approve the audit result, he can appeal the audit result. Therefore, by counting the number of claims for which the user has appealed the audit result, the number of claims with wrong audit results can be indirectly determined; for example, The claims application can be reviewed manually. When there are few claims, manual review can be conducted. If there are many claims, manual review can be conducted according to a certain percentage of samples, and statistical review can be made to determine the claims with wrong verification results. Quantity.

Of course, the specific way of determining the number of claims with errors in the review result is not limited to the above two ways, and each way can be applied individually or jointly, which is not limited in the embodiments of this specification.

After calculating the prediction accuracy rate, compare the calculation result with a preset accuracy rate threshold, and in the case where the prediction accuracy rate does not reach the preset accuracy rate threshold, use the claim application with an erroneous review result as a negative sample to optimize the claim Review the model.

After the claim application is reviewed, the actual amount of compensation can be further determined. In a specific implementation of this specification, when the claim application is determined to be passed, the scope of compensation scenarios and Range of compensation.

For example, you can first determine the insured amount of the claim policy and the historical claim amount, and then calculate the claimable amount of the claim based on the difference between the insurance amount and the historical claim amount to obtain the corresponding amount of the claimable amount Range of compensation.

Then extract the amount of claim for compensation from the claim certificate. This amount can be filled in by the user, or it can be calculated based on the cost details in the proof of claim. Determine the amount of the claim amount that meets the range of the claim scenario and the amount of claim amount to obtain the actual amount of claim for this claim application.

For example, determine the first amount of the claim settlement amount that meets the scope of the compensation scenario, determine whether the first amount is greater than the compensable amount corresponding to the range of the compensation amount, and if not, determine the first One amount is the actual payment amount of the claim application.

In the case of greater than, you can directly end the claims process, or prompt the user that the amount of compensation is insufficient. In addition, some insurance institutions can support the advance payment of a certain amount of compensation, or the protection function of certain types of insurance (such as order insurance) is to realize fast claims through the advance of the amount of compensation, so that users can get a good claims experience.

In the above case, the claim risk value of the insured of the claim policy may be further obtained, and the claim risk value is used to indicate the probability of successful recovery after the payment of the claim amount. Taking order insurance as an example, a certain compensation risk value can be set corresponding to the seller's level, business hours, business reputation, etc. on the shopping platform. The higher the level, the longer the business time, the better the business reputation, the compensation risk value Lower. It is judged whether the risk value of the compensation meets the preset advance payment condition; if it is, the first amount is determined as the actual compensation amount of the claim application, and the advance payment is made.

Finally, according to the actual compensation amount, the compensation user is compensated.

For the above-mentioned advance payment situation, when calculating the claimable amount of the claim based on the difference between the sum assured and the historical claim amount, and obtaining the claim amount range corresponding to the claimable amount, it is possible to further determine Declaring the claimed amount of the claim, calculating the sum of the sum insured and the amount recovered, and calculating the claimable amount of the claim based on the difference between the calculated sum and the historical claim The amount of compensation corresponding to the amount of compensation.

In a specific implementation of this specification, if the claim application fails to pass the review, the user may be further prompted why it failed. Specifically, when it is determined that the claim application does not pass, the reason for the failure of the claim application can be determined according to the output result of the claim review model; the reasons include at least: non-compliance with the claim rules, failure to meet credit requirements, And/or there is a risk of fraud. Of course, there may be other reasons, which are not limited in the embodiments of this specification.

In the following, a more specific example will be used to explain the processing method of the claims business provided in this manual.

As shown in Figure 2, suppose that a buyer of an e-commerce platform needs to return the goods after the transaction, and initiates a return application for the transaction order, and because the seller insures the transaction commodity for order insurance, the insurance institution's claims system can automatically The order initiates a claim application.

The claim data of the claim application will include the policy identification (such as the policy number), the user identification (such as the buyer ID) and the proof of claim (such as the transaction order transaction amount, time, return details and other details).

First of all, according to the policy number, you can get the compensation rules corresponding to the policy information of the insurance policy that needs to be settled, such as the maximum compensation amount for the order, whether it is possible to pay for different return reasons, and so on. In addition, the buyer's credit data can be obtained based on the buyer ID, such as its credit score on the e-commerce platform, historical shopping records, historical returns records, historical transaction evaluation records, and so on.

Then you can extract the preset rule features from the proof of claim and extract the preset credit features from the credit data. Therefore, the features are input into the pre-trained claim review model to calculate whether the claim certificate complies with the claim rules, whether the buyer's credit meets the preset requirements, and whether there is a risk of fraud and fraud in this claim. In the case where it is determined that it meets the claims rules, the credit meets the requirements, and there is no risk of fraud, the predicted results of the claims that have passed the audit can be output, otherwise the predicted results of the claims that have not passed the audit can be output.

If the claim does not pass the review, determine the reasons for the failure, such as non-compliance with the claim rules, credit not meeting the requirements, and fraud risk, etc., and return the corresponding instructions to the user to facilitate the user to understand or further appeal the review result.

If the claim is approved, you can further determine the actual amount of compensation, based on the preset amount calculation model: Compensable amount = sum assured-historical compensation amount + recovered amount, and calculate the current compensable amount, of which the historical compensation amount can be Including outstanding and settled compensation amounts, the recovered amount can refer to the seller to repay the amount.

In addition, the user can fill in the refund amount when initiating the return application, or the return refund system can automatically calculate the refund amount based on the transaction order and the reason for the return, and obtain the corresponding claim amount based on the refund amount. If the claim amount is not greater than the calculated compensable amount, you can directly make compensation; if the claim amount is greater than the calculated compensable amount, you can further determine the seller's compensation risk value.

Specifically, different payment risk values can be set for buyers of different levels in the e-commerce platform, and different advanceable amounts can be set. For example, the seller with the highest level has the lowest payment risk value, which corresponds to an advance payment of 50,000 yuan . Determine whether the advanceable amount corresponding to the seller's compensation risk value is enough to advance the part of the application claim amount that is greater than the compensable amount. If so, advance all or part of the actual compensation amount for the seller and initiate a recovery process for the seller.

It can be seen that the application of the above scheme can eliminate the problem of long claim review time in the artificial claim operation process, simplify the claim process, and improve the efficiency of claims. In addition, it can provide buyers with fast claims settlement services, improve the timeliness of sellers' service capabilities, and at the same time protect the assets of insurance institutions.

Corresponding to the above method embodiment, an embodiment of the present specification also provides a claims processing device. Referring to FIG. 3, the device may include:

The data obtaining module 110 is used to obtain the claim data in the claim application. The claim data includes at least the policy identification, the user identification and the proof of claim; and, according to the policy identification, obtain the claim rules corresponding to the policy information of the claim insurance policy ; And, based on the user identification, obtain the credit data of the claiming user;

The input module 120 is used to determine several rule features to be extracted according to the preset correspondence between the claim rules and rule features, and extract the rule features from the claim certificate; and, from the credit data Extract preset credit features;

The output module 130 is used to input the extracted features into the pre-trained claims review model, and determine whether the claim application is passed according to the output results of the model; wherein, the device that obtains the output results according to the input features includes: according to the input rules Feature, calculate whether the claim certificate complies with the claim rules; based on the input credit feature, calculate whether the claim user has reached a preset credit requirement and/or whether a fraud risk has reached a preset threshold.

In a specific embodiment provided in this specification, referring to FIG. 4, the apparatus may further include a model optimization module 140, which may specifically include:

The accuracy rate calculation sub-module is used to determine the number of claim applications with erroneous review results for each claim application that has been reviewed, and calculate the predicted accuracy rate of the claim review model according to the number;

The model optimization sub-module is used to optimize the claims review model by using a claim application with a wrong review result as a negative sample when the predicted accuracy rate does not reach the preset accuracy rate threshold.

In a specific implementation provided by this specification, the accuracy calculation submodule may be specifically used for:

Count the number of claims submitted by users to appeal against the review results; and/or

Manually review all or part of the claims application, and statistically review to determine the number of claims applications with incorrect review results.

In a specific embodiment provided by this specification, referring to FIG. 4, the device may further include:

The reason determination module 150 is used to determine the reason why the claim application fails according to the output result of the claim review model when it is determined that the claim application fails; the reasons include at least: non-compliance with the claim rules and credit failure Meet the requirements and/or risk of fraud.

In a specific embodiment provided in this specification, referring to FIG. 4, the device may further include an amount compensation module 160, which may specifically include:

The scope determination sub-module is used to determine the scope of the compensation scenario and the scope of the compensation amount as stipulated in the settlement rules when the claim application is approved;

The amount calculation sub-module is used to extract the amount of claim from the claim certificate, and determine the amount of the amount of claim that meets the scope of the claim scenario and the amount of claim to obtain the actual amount of claim for this claim;

Amount compensation sub-module, which is used to compensate the claims user based on the actual compensation amount.

In a specific implementation provided by this specification, the range determination submodule may include:

Amount determination unit, used to determine the insured amount and historical payment amount of the claim policy;

The range determination unit is configured to calculate the claimable amount of the claim based on the difference between the sum assured and the historical claim amount, and obtain a claim amount range corresponding to the claimable amount.

In a specific implementation provided by this specification, the amount calculation submodule may include:

A first amount determining unit, configured to determine a first amount that meets the scope of the compensation scenario in the amount of claims for compensation;

The amount comparison unit is used to determine whether the first amount is greater than the compensable amount corresponding to the range of the amount of compensation;

The compensation amount determination unit is used to determine that the first amount is the actual payment amount of the claim application if it is not greater than.

In a specific embodiment provided by this specification, the amount calculation submodule may further include:

The claim risk determination unit is used to obtain the claim risk value of the insured of the claim policy in the case of greater than, and the claim risk value is used to indicate the probability of successful recovery after the advance payment of the claim amount;

The advance payment condition judgment unit is used to judge whether the compensation risk value meets the preset advance payment conditions; if so, determine that the first amount is the actual payment amount for the claim application.

In a specific embodiment provided in this specification, the range determination unit may specifically be used for:

Determine the amount of the claimed insurance policy that has been recovered;

Calculating the sum of the insured amount and the recovered amount, and calculating the deductible amount of the claim policy based on the difference between the calculated sum and the historical indemnity amount to obtain a range of indemnity amounts corresponding to the indemnable amount .

It can be understood that the model optimization module 140, the cause determination module 150, and the amount compensation module 160 are three functionally independent modules that can be configured in the device at the same time as shown in FIG. 4 or separately in the device, so The structure shown in FIG. 4 should not be construed as limiting the solution of the embodiments of this specification.

For the implementation process of the functions and functions of each module in the above device, please refer to the implementation process of the corresponding steps in the above method for details, which will not be repeated here.

An embodiment of the present specification also provides a computer device, which includes at least a memory, a processor, and a computer program stored on the memory and executable on the processor, where the processor implements the program to implement the foregoing claims processing method . The method includes at least:

A method for processing claims, the method includes:

FIG. 5 shows a schematic diagram of a more specific hardware structure of a computing device provided by an embodiment of the present specification. The device may include: a processor 1010, a memory 1020, an input/output interface 1030, a communication interface 1040, and a bus 1050. The processor 1010, the memory 1020, the input/output interface 1030, and the communication interface 1040 realize the communication connection between the devices within the device through the bus 1050.

The processor 1010 may be implemented by a general-purpose CPU (Central Processing Unit, central processing unit), a microprocessor, an application specific integrated circuit (Application Specific Integrated Circuit, ASIC), or one or more integrated circuits, etc. Programs to implement the technical solutions provided by the embodiments of this specification.

The memory 1020 may be implemented in the form of ROM (Read Only Memory, Read Only Memory), RAM (Random Access Memory, Random Access Memory), static storage devices, and dynamic storage devices. The memory 1020 may store an operating system and other application programs. When the technical solutions provided by the embodiments of the present specification are implemented by software or firmware, related program codes are stored in the memory 1020 and are called and executed by the processor 1010.

The input/output interface 1030 is used to connect input/output modules to realize information input and output. The input/output/module can be configured as a component in the device (not shown in the figure), or can be externally connected to the device to provide corresponding functions. The input device may include a keyboard, mouse, touch screen, microphone, various sensors, etc., and the output device may include a display, a speaker, a vibrator, an indicator light, and the like.

The communication interface 1040 is used to connect a communication module (not shown in the figure) to implement communication interaction between the device and other devices. The communication module can realize communication through a wired method (such as USB, network cable, etc.), and can also realize communication through a wireless method (such as mobile network, WIFI, Bluetooth, etc.).

The bus 1050 includes a path for transferring information between various components of the device (eg, processor 1010, memory 1020, input/output interface 1030, and communication interface 1040).

It should be noted that although the above device only shows the processor 1010, the memory 1020, the input/output interface 1030, the communication interface 1040, and the bus 1050, in the specific implementation process, the device may also include necessary for normal operation Other components. In addition, those skilled in the art may understand that the above-mentioned device may also include only the components necessary to implement the solutions of the embodiments of the present specification, rather than including all the components shown in the figures.

Embodiments of the present specification also provide a computer-readable storage medium on which a computer program is stored, and when the program is executed by a processor, the foregoing claims processing method is realized. The method includes at least:

A method for processing claims, the method includes:

Computer-readable media, including permanent and non-permanent, removable and non-removable media, can store information by any method or technology. The information may be computer readable instructions, data structures, modules of programs, or other data. Examples of computer storage media include, but are not limited to, phase change memory (PRAM), static random access memory (SRAM), dynamic random access memory (DRAM), other types of random access memory (RAM), read-only memory (ROM), electrically erasable programmable read-only memory (EEPROM), flash memory or other memory technologies, read-only compact disc read-only memory (CD-ROM), digital versatile disc (DVD) or other optical storage, Magnetic tape cassettes, magnetic tape magnetic disk storage or other magnetic storage devices or any other non-transmission media can be used to store information that can be accessed by computing devices. As defined in this article, computer-readable media does not include temporary computer-readable media (transitory media), such as modulated data signals and carrier waves.

It can be known from the description of the above implementation manners that those skilled in the art can clearly understand that the embodiments of this specification can be implemented by means of software plus a necessary general hardware platform. Based on this understanding, the technical solutions of the embodiments of the present specification can be embodied in the form of software products in essence or part of contributions to the existing technology, and the computer software products can be stored in a storage medium such as ROM/RAM, Magnetic disks, optical disks, etc., include several instructions to enable a computer device (which may be a personal computer, server, or network device, etc.) to perform the methods described in the embodiments of this specification or some parts of the embodiments.

The system, device, module or unit explained in the above embodiments may be specifically implemented by a computer chip or entity, or implemented by a product with a certain function. A typical implementation device is a computer, and the specific form of the computer may be a personal computer, a laptop computer, a cellular phone, a camera phone, a smart phone, a personal digital assistant, a media player, a navigation device, an email sending and receiving device, and a game control Desk, tablet computer, wearable device, or any combination of these devices.

The embodiments in this specification are described in a progressive manner. The same or similar parts between the embodiments can be referred to each other. Each embodiment focuses on the differences from other embodiments. In particular, for the device embodiments, since they are basically similar to the method embodiments, the description is relatively simple, and the relevant parts can be referred to the description of the method embodiments. The device embodiments described above are only schematic, wherein the modules described as separate components may or may not be physically separated, and the functions of the modules may be the same when implementing the embodiment solutions of the present specification Or multiple software and/or hardware. It is also possible to select some or all of the modules according to actual needs to achieve the purpose of the solution of this embodiment. Those of ordinary skill in the art can understand and implement without paying creative labor.

The above is only a specific implementation manner of the embodiments of this specification. It should be pointed out that for those of ordinary skill in the art, without departing from the principles of the embodiments of this specification, several improvements and retouches can be made. These Improvements and retouching should also be regarded as the scope of protection of the embodiments of this specification.

Claims

A method for processing claims, the method includes:

Obtain the claim data in the claim application, the claim data at least includes: policy identification, user identification and proof of claim;

According to the policy identification, obtain a claim rule corresponding to the policy information of the insurance policy to be claimed; and, according to the user identification, obtain credit data of the claim user;

Determine a number of rule features to be extracted according to the preset correspondence relationship between the claim rules and rule features, and extract the rule features from the claim certificate; and, extract a preset number of credits from the credit data feature;

Input the extracted features into a pre-trained claim review model, and determine whether the claim application is passed according to the output of the model; wherein, the method for obtaining the output result according to the input features includes: calculating the claims according to the input rule features Proof of compliance with the claims rules; based on the entered credit characteristics, it is calculated whether the claims user meets the preset credit requirements and/or whether the fraud risk reaches the preset threshold.
The method of claim 1, further comprising:

For each claim application that has been reviewed, determine the number of claim applications that have erroneous review results, and calculate the prediction accuracy of the claim review model based on this number;

In the case that the prediction accuracy rate does not reach the preset accuracy rate threshold, the claim application with an error in the review result is taken as a negative sample to optimize the claim review model.
According to the method of claim 2, the determination of the number of claims with erroneous review results includes:

Count the number of claims submitted by users to appeal against the review results; and/or

Manually review all or part of the claims application, and statistically review to determine the number of claims applications with incorrect review results.
The method of claim 1, further comprising:

When it is determined that this claim application is not passed, based on the output of the claim review model, determine the reason for the failure of the claim application; the reasons include at least: non-compliance with the claim rules, credit failure, and/or existence Fraud risk.
The method of claim 1, further comprising:

When it is determined that this claim application is approved, determine the scope of the compensation scenario and the amount of compensation prescribed in the claims rules;

Extract the amount of claim for compensation from the claim certificate, and determine the amount of the amount of claim for compensation that meets the scope of the payment scenario and the amount of claim, to obtain the actual amount of claim for this claim application;

According to the actual compensation amount, the compensation user is compensated.
According to the method of claim 5, the determination of the range of compensation amounts specified in the claims rules includes:

Determine the insured amount and historical payment amount of the said claim policy;

Based on the difference between the insured amount and the historical compensation amount, the deductible amount of the claim insurance policy is calculated to obtain a range of compensation amounts corresponding to the deductible amount.
According to the method of claim 6, the determining the amount of the claim amount that meets the range of the payment scenario and the amount of claim amount to obtain the actual amount of claim for the claim application includes:

Determine the first amount in the amount of claims for compensation that meets the scope of the payment scenario;

Determining whether the first amount is greater than the deductible amount corresponding to the range of the amount of compensation;

In the case of not more than, it is determined that the first amount is the actual payment amount of the claim application.
The method of claim 7, further comprising:

In the case of greater than, the insurance risk value of the insured who obtained the claim policy, the insurance risk value is used to indicate the probability of successful recovery after the payment of the payment amount;

Judge whether the compensation risk value meets the preset advance payment conditions; if so, determine that the first amount is the actual payment amount for the claim application.
According to the method of claim 8, the calculating the claimable amount of the claim according to the difference between the insurance amount and the historical claim amount to obtain a range of claims corresponding to the claimable amount includes:

Determine the amount of the claimed insurance policy that has been recovered;

Calculating the sum of the insured amount and the recovered amount, and calculating the deductible amount of the claim policy based on the difference between the calculated sum and the historical indemnity amount to obtain a range of indemnity amounts corresponding to the indemnable amount .
A claims processing device, the device includes:

The data obtaining module is used to obtain the claim data in the claim application. The claim data includes at least: the policy identification, the user identification, and the proof of claim; and, according to the policy identification, obtain the claim rules corresponding to the policy information of the claim insurance policy; And, according to the user identification, obtain credit data of the claiming user;

The input module is used to determine several rule features to be extracted based on the preset correspondence between the claim rules and rule features, and extract the rule features from the claim certificate; and, extract from the credit data Several preset credit characteristics;

The output module is used to input the extracted features into the pre-trained claims review model, and determine whether the claim application is passed according to the output results of the model; the device that obtains the output results based on the input features includes: according to the input rule features , Calculate whether the claim certificate complies with the claim rules; based on the input credit characteristics, calculate whether the claim user meets the preset credit requirements and/or whether the fraud risk reaches the preset threshold.
The apparatus according to claim 10, further comprising a model optimization module, specifically including:

The accuracy rate calculation sub-module is used to determine the number of claim applications with erroneous review results for each claim application that has been reviewed, and calculate the predicted accuracy rate of the claim review model according to the number;

The model optimization sub-module is used to optimize the claims review model by using a claim application with a wrong review result as a negative sample when the predicted accuracy rate does not reach the preset accuracy rate threshold.
According to the apparatus of claim 11, the accuracy calculation submodule is specifically used to:

Count the number of claims submitted by users to appeal against the review results; and/or

Manually review all or part of the claims application, and statistically review to determine the number of claims applications with incorrect review results.
The apparatus according to claim 10, further comprising:

The reason determination module is used to determine the reason why the claim application fails according to the output result of the claim review model when it is determined that the claim application does not pass; Requirements, and/or risk of fraud.
The device according to claim 10, further comprising an amount compensation module, specifically including:

The scope determination sub-module is used to determine the scope of the compensation scenario and the scope of the compensation amount as stipulated in the settlement rules when the claim application is approved;

The amount calculation sub-module is used to extract the amount of claim from the claim certificate, and determine the amount of the amount of claim that meets the scope of the claim scenario and the amount of claim to obtain the actual amount of claim for this claim;

Amount compensation sub-module, which is used to compensate the claims user based on the actual compensation amount.
The apparatus according to claim 14, the range determination submodule comprising:

Amount determination unit, used to determine the insured amount and historical payment amount of the claim policy;

The range determination unit is configured to calculate the claimable amount of the claim based on the difference between the sum assured and the historical claim amount, and obtain a claim amount range corresponding to the claimable amount.
The apparatus according to claim 15, wherein the amount calculation sub-module includes:

A first amount determining unit, configured to determine a first amount that meets the scope of the compensation scenario in the amount of claims for compensation;

The amount comparison unit is used to determine whether the first amount is greater than the compensable amount corresponding to the range of the amount of compensation;

The compensation amount determination unit is used to determine that the first amount is the actual payment amount of the claim application if it is not greater than.
The apparatus of claim 16, the amount calculation sub-module, further comprising:

The claim risk determination unit is used to obtain the claim risk value of the insured of the claim policy in the case of greater than, and the claim risk value is used to indicate the probability of successful recovery after the advance payment of the claim amount;

The advance payment condition judgment unit is used to judge whether the compensation risk value meets the preset advance payment conditions; if so, determine that the first amount is the actual payment amount for the claim application.
The apparatus according to claim 17, the range determining unit is specifically configured to:

Determine the amount of the claimed insurance policy that has been recovered;

Calculating the sum of the insured amount and the recovered amount, and calculating the deductible amount of the claim policy based on the difference between the calculated sum and the historical indemnity amount to obtain a range of indemnity amounts corresponding to the indemnable amount .
A computer device, including a memory, a processor, and a computer program stored on the memory and executable on the processor, wherein when the processor executes the program, the program according to any one of claims 1 to 9 is implemented method.