CN107705211A - A kind of adjustment method and apparatus of settlement of insurance claim case - Google Patents
A kind of adjustment method and apparatus of settlement of insurance claim case Download PDFInfo
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- CN107705211A CN107705211A CN201711111127.0A CN201711111127A CN107705211A CN 107705211 A CN107705211 A CN 107705211A CN 201711111127 A CN201711111127 A CN 201711111127A CN 107705211 A CN107705211 A CN 107705211A
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Abstract
This application discloses a kind of adjustment method and apparatus of settlement of insurance claim case, wherein, methods described includes：Obtain the Claims Resolution data of settlement of insurance claim case to be adjusted；Settlement of insurance claim case to be adjusted is selected to need the target service rule verified from pre-recorded business rule；According to target service rule and Claims Resolution data, treat adjustment settlement of insurance claim case and carry out adjustment verification；If settlement of insurance claim case to be adjusted verifies by adjusting, according to Claims Resolution data, the amount for which loss settled of settlement of insurance claim case to be adjusted is adjusted.So, the adjustment checking procedure of whole settlement of insurance claim case to be adjusted is without manually participating in, the amount for which loss settled of adjustment settlement of insurance claim case can be realized automatically, substantial amounts of human resources can so be saved, save the time of adjustment examination ＆ verification, it can avoid, due to manually participating in the error brought, reducing error rate, effectively improving the accuracy of adjustment examination ＆ verification.
Description
Technical field
The application belongs to settlement of insurance claim technical field, more particularly to the adjustment method and dress of a kind of settlement of insurance claim case
Put.
Background technology
With present people living standard improve, increasing people can by a part of fund input insurance company etc.,
So insurance company needs Claims Resolution case to be processed more and more, and user needs to ask for compensation to insurance company after Claims Resolution case generation
Repay, now insurance company will be directed to each Claims Resolution case and carry out adjustment examination ＆ verification, show that corresponding indemnity is supplied to user.
At present, for user when settlement of insurance claim is applied for, staff can establish settlement of insurance claim case task in system, and
Typing settles a claim bill into system accordingly, then goes adjustment to audit these insurances for being entered into system by special staff
Claims Resolution case.Specifically, special staff is manually selecting the declaration form of user first on adjustment interface, then basis has been recorded
Enter and to the expense item on the subscriber's account of system, select the responsibility defined in the declaration form detailed, finally click on adjustment button
Realize adjustment bill amount for which loss settled.
However, the mode of above-mentioned this adjustment amount for which loss settled needs to take substantial amounts of human resources, if on subscriber's account
Expense item it is more or when needing the settlement of insurance claim case adjusted more, when this artificial adjustment mode can consume longer
Between, and error rate is higher, and then have impact on the timeliness and accuracy of settlement of insurance claim.
The content of the invention
In view of this, this application provides a kind of adjustment method and apparatus of settlement of insurance claim case, main purpose to be to solve
Certainly manually the mode of adjustment settlement of insurance claim case can consume longer time, and error rate is higher, influences the timeliness of settlement of insurance claim
And the problem of accuracy.
First aspect according to the application, there is provided a kind of adjustment method of settlement of insurance claim case, methods described include：
Obtain the Claims Resolution data of settlement of insurance claim case to be adjusted；
Settlement of insurance claim case to be adjusted described in selection needs the target service rule verified from pre-recorded business rule
Then；
According to the regular and described Claims Resolution data of the target service, adjustment school is carried out to the settlement of insurance claim case to be adjusted
Test；
If the settlement of insurance claim case to be adjusted verifies by adjusting, according to the Claims Resolution data, wait to manage described in adjustment
Calculate the amount for which loss settled of settlement of insurance claim case.
Second aspect according to the application, there is provided a kind of adjustment device of settlement of insurance claim case, described device include：
Acquiring unit, for obtaining the Claims Resolution data of settlement of insurance claim case to be adjusted；
Selecting unit, need to verify for settlement of insurance claim case to be adjusted described in the selection from pre-recorded business rule
Target service rule；
Verification unit, for according to the regular and described Claims Resolution data of the target service, to the settlement of insurance claim to be adjusted
Case carries out adjustment verification；
Unit is adjusted, if for settlement of insurance claim case adjust by adjustment verification, according to the Claims Resolution data,
The amount for which loss settled of settlement of insurance claim case to be adjusted described in adjustment.
The third aspect according to the application, there is provided a kind of storage device, be stored thereon with computer program, described program quilt
The adjustment method of the settlement of insurance claim case described in first aspect is realized during computing device.
Fourth aspect according to the application, there is provided a kind of entity apparatus of settlement of insurance claim case adjustment, described device include
Storage device and processor,
The storage device, for storing computer program；
The processor, for performing the computer program to realize the reason of the settlement of insurance claim case described in first aspect
Calculation method.
By above-mentioned technical proposal, a kind of adjustment method and apparatus for settlement of insurance claim case that the application provides are and current
The mode of artificial adjustment settlement of insurance claim case is compared, and can obtain the Claims Resolution data of settlement of insurance claim case to be adjusted automatically, and
The corresponding target service rule with settlement of insurance claim case to be adjusted selected from pre-recorded business rule, is settling a claim
After data are verified according to target service rule by adjustment, corresponding amount for which loss settled is adjusted automatically according still further to Claims Resolution data.So,
The adjustment checking procedure of whole settlement of insurance claim case to be adjusted can realize adjustment settlement of insurance claim case automatically without manually participating in
Amount for which loss settled, can so save substantial amounts of human resources, save the time of adjustment examination ＆ verification, can avoid participating in due to artificial
The error brought, error rate is reduced, effectively improve the accuracy of adjustment examination ＆ verification.
Described above is only the general introduction of technical scheme, in order to better understand the technological means of the application,
And can be practiced according to the content of specification, and in order to allow above and other objects, features and advantages of the application can
Become apparent, below especially exemplified by the embodiment of the application.
Brief description of the drawings
By reading the detailed description of hereafter preferred embodiment, it is various other the advantages of and benefit it is common for this area
Technical staff will be clear understanding.Accompanying drawing is only used for showing the purpose of preferred embodiment, and is not considered as to the application
Limitation.And in whole accompanying drawing, identical part is denoted by the same reference numerals.In the accompanying drawings：
Fig. 1 is the method flow diagram of one embodiment of the adjustment method of the settlement of insurance claim case of the application；
Fig. 2 is the method flow diagram of another embodiment of the adjustment method of the settlement of insurance claim case of the application；
Fig. 3 is the method flow diagram of the further embodiment of the adjustment method of the settlement of insurance claim case of the application；
Fig. 4 is the structural representation of one embodiment of the adjustment device of the settlement of insurance claim case of the application；
Fig. 5 is the structural representation of another embodiment of the adjustment device of the settlement of insurance claim case of the application；
Fig. 6 is the structural representation of the further embodiment of the adjustment device of the settlement of insurance claim case of the application；
Fig. 7 is the entity structure schematic diagram of the adjustment device of the settlement of insurance claim case of the application.
Embodiment
The exemplary embodiment of the disclosure is more fully described below with reference to accompanying drawings.Although the disclosure is shown in accompanying drawing
Exemplary embodiment, it being understood, however, that may be realized in various forms the disclosure without should be by embodiments set forth here
Limited.On the contrary, these embodiments are provided to facilitate a more thoroughly understanding of the present invention, and can be by the scope of the present disclosure
Completely it is communicated to those skilled in the art.
The embodiment of the present application provides a kind of adjustment method of settlement of insurance claim case, can be automatically one or more insurances
Settle a claim case adjustment amount for which loss settled, while manpower is saved, additionally it is possible to save adjustment audit time, can effectively avoid by
In the error for manually participating in bringing, and then reduce error rate.
As shown in figure 1, the step of adjustment method of the settlement of insurance claim case of the present embodiment, includes：
Step 101, the Claims Resolution data of settlement of insurance claim case to be adjusted are obtained.
Wherein, data of settling a claim can include Claims Resolution billing data, declaration form data etc.；Claims Resolution billing data includes：Therapeutic machine
Structure and personal information, Claims Resolution case status information, the International Classification of Diseases information of user's Claims Resolution, treatment type information, accident class
Type information etc.；Declaration form data include：Declaration form insurance kind information, policy type information, declaration form insured amount information, declaration form responsibility are detailed
Information etc.；Declaration form responsibility managing detailed catalogue includes：The detailed mark of responsibility, ratio is compensated, scope is compensated, compensates limit, compensates condition
Deng.
Executive agent for the present embodiment can be to realize that settlement of insurance claim case adjusts the device of examination ＆ verification automatically, automatic reason
The amount for which loss settled of settlement of insurance claim case to be adjusted is calculated, and then can help to accelerate settlement of insurance claim processing.When the device works,
The Claims Resolution data of multiple settlement of insurance claim cases to be adjusted can be obtained respectively simultaneously, and by the Claims Resolution data and phase of acquisition
The settlement of insurance claim case to be adjusted answered is corresponded, and Claims Resolution data and corresponding settlement of insurance claim case to be adjusted are preserved
In temporary storage, related Claims Resolution data can be so transferred from the temporary storage when needing to use Claims Resolution data.
After the amount for which loss settled adjustment of some settlement of insurance claim case to be adjusted understands, will by the settlement of insurance claim case to be adjusted and its
Corresponding Claims Resolution data are removed from temporary storage.
Step 102, settlement of insurance claim case to be adjusted is selected to need the target industry verified from pre-recorded business rule
Business rule.
Wherein, pre-recorded business rule can include：The verification of risk medical institutions, personal screening verification, palpus shielding
Declaration form especially arranges attribute verification, more declaration forms from core qualification verification, hospital's property verification, declaration form under case status check, case
Verification, International Classification of Diseases (international Classification of diseases, ICD) code check, afterwards
The verification of case Third-party payment, the verification of bill quantity, the attributes verification of pre-granted, treatment type checking, insurance kind verification, material languages
Verification, currency type verification, accident pattern verification, big customer's insurance application bit check, the thin item amount verification of adjustment responsibility, responsibility are detailed tactile
Hair verification etc..
In the above-mentioned technical solutions, actual conditions that can be by user according to settlement of insurance claim case to be adjusted, dynamically from pre-
Suitable business rule is selected in each business rule first recorded, as the target service rule for needing to verify；Can also be pre-
First count different classes of settlement of insurance claim case respectively corresponding to each target service rule, needing to treat adjustment settlement of insurance claim
When case is verified, according to the classification of the settlement of insurance claim case to be adjusted, it is suitable to be selected from pre-recorded business rule
Business rule as target service rule.
In addition, can also be in advance the identity identification information point of different settlement of insurance claim cases according to practical business demand
Not Pei Zhi corresponding to target service rule, treat adjustment settlement of insurance claim case verified when, obtain settlement of insurance claim to be adjusted
The identity identification information of case, carried out from pre-recorded business rule selecting corresponding business according to the identity identification information
Rule is as the target service rule verified with settlement of insurance claim case to be adjusted needs.Wherein, identity identification information can include
Insurer's identification card number, warrantee's identification card number, the Quick Response Code of settlement of insurance claim case to be adjusted, settlement of insurance claim case to be adjusted
The digital authenticating code etc. of bar code, settlement of insurance claim case to be adjusted.
For example, according to the actual conditions of settlement of insurance claim case to be adjusted, it is suitable to be selected from pre-recorded business rule
Business rule, each target service rule for needing to verify as the case, such as the doctor of user settle a claim treatment in the case
It is that regular medical institutions in white list, hospital's property be Grade A hospital to treat mechanism, and the user be non-black list user, it is nearest
The Claims Resolution bill quantity of the user is less than certain threshold value in one month, the corresponding type of insurance meets Claims Resolution requirement, corresponding accident category
In Claims Resolution accident scope, Claims Resolution bill be to be paid by RMB.
Step 103, according to target service rule and Claims Resolution data, treat adjustment settlement of insurance claim case and carry out adjustment verification.
In the above-mentioned technical solutions, the Claims Resolution data of settlement of insurance claim case to be adjusted are transferred one by one from temporary storage,
And Claims Resolution data are subjected to adjustment verification according to target service rule, judge whether corresponding Claims Resolution data meet target service rule
Adjustment verification standard in then, determines the settlement of insurance claim case to be adjusted by adjusting school if adjustment verification standard is met
Test, if not meeting adjustment verification standard, it is determined that settlement of insurance claim case to be adjusted verifies not over adjustment, can subsequently lead to
Cross the mode manually adjusted and adjustment examination ＆ verification is carried out to it, or temporarily first audited without automatic adjustment, and periodically it is carried out
Adjustment verification detection, after it meets adjustment verification standard, then carries out adjusting review process automatically.
For example, based on the example in step 102, being determined when meeting these above-mentioned condition (target service principles) simultaneously should
Case meets adjustment verification standard, i.e. the case is verified by adjusting.
Step 104, if settlement of insurance claim case to be adjusted is verified by adjusting, according to Claims Resolution data, adjust and treat that adjustment is protected
The amount for which loss settled of danger Claims Resolution case.
In the above-mentioned technical solutions, transfer by adjust verification settlement of insurance claim case adjust Claims Resolution billing data with
Declaration form data, according to the bill expense in the Claims Resolution billing data, and inquire about the duty being adapted in declaration form data with the bill expense
Appoint detail, inquiry corresponding with the bill expense settle a claim ratio and Claims Resolution limit, then adjusted according to these data, will be every
The adjustment amount of money of one bill expense is added up to obtain total amount for which loss settled, and then user is entered according to total amount for which loss settled
Row Claims Resolution operation.
For example, certain user has bought a personal accident danger in insurance company, after the user, which walks, to be scratched, hold hospital and examine
The disconnected bill that proves and pay the fees is settled a claim to insurance company, and insurance company establishes corresponding Claims Resolution case task and in the bill number
After input system, insurance company starts the adjustment mechanism of the settlement of insurance claim case of the application offer, specific to obtain system typing
The billing data, and the declaration form data of the user are inquired about, based on the billing data and declaration form data, from pre-recorded business
Select the case to need the target service rule verified in rule, Claims Resolution verification is carried out to the case, such as judge that the user treats
Medical institutions whether be regular medical institutions in white list, hospital's property whether be Grade A hospital, and the user whether be
Whether non-black list user, the type of insurance of corresponding declaration form meet Claims Resolution requirement etc., if this has passed through Claims Resolution verification, carry out
Follow-up adjustment operation, the bill expense in the billing data, and inquire about the duty being adapted in declaration form data with the bill expense
Appoint detail, inquiry corresponding with the bill expense settle a claim ratio and Claims Resolution limit, then adjusted according to these data, according to
The amount for which loss settled of adjustment carries out Claims Resolution operation to the user.
Pass through above-mentioned technical proposal, entirely the adjustment checking procedure of settlement of insurance claim case to be adjusted, can without manually participating in
With the amount for which loss settled of automatic realization adjustment settlement of insurance claim case, substantial amounts of human resources can be so saved, save adjustment examination ＆ verification
Time, can avoid, due to manually participating in the error brought, reducing error rate, effectively improving the accuracy of adjustment examination ＆ verification.
As shown in figure 4, in a particular embodiment, then step 104 specifically includes：
Step 1041, general expenses information is extracted from billing data to be settled a claim；And blamed from declaration form extracting data is every
Appoint managing detailed catalogue.
Step 1042, general expenses information is matched respectively with every responsibility managing detailed catalogue.
Step 1043, foundation matching result, the amount for which loss settled of settlement of insurance claim case to be adjusted is adjusted.
In the above-mentioned technical solutions, the billing data to be settled a claim in data of settling a claim and corresponding declaration form data are divided
From, and satisfactory general expenses information (for example, cost of hospitalization, expenses for medicine, Operation Fee etc.) is extracted from billing data to be settled a claim.
Because the declaration form data of settlement of insurance claim case corresponding to some clients are more, such insurance company is just needed from multiple
Selected in declaration form data and the most suitable declaration form data of the settlement of insurance claim case of client.Each declaration form number first to getting
According to automatic Verification is carried out, then judge whether each declaration form data meet predetermined standard, and the guarantor that will not meet preassigned
Forms data is rejected, finally by the declaration form data obtained after rejecting according to the time of policy purchase either most Dali of expiration time or compensation
Pay for the amount of money and establish priority, and the declaration form data of highest priority are defined as final declaration form data.
The every responsibility managing detailed catalogue corresponding with general expenses information from final declaration form extracting data, it is bright according to responsibility
Thin information judges whether corresponding cost information meets Claims Resolution standard, if so, then retaining corresponding cost information, if it is not, then
The cost information is rejected.All cost informations that screening obtains are carried out into adjustment to add up, obtain final amount for which loss settled.
In a particular embodiment, step 1043 specifically includes：
Step 10431, with reference to the Claims Resolution limit in the responsibility managing detailed catalogue matched with cost information and Claims Resolution ratio, adjustment
Amount for which loss settled corresponding to general expenses information and addition obtain Claims Resolution total amount.
Step 10432, the maximum Claims Resolution limit of declaration form product of settle a claim total amount and settlement of insurance claim case to be adjusted is carried out
Compare, whether the total amount that judges to settle a claim is less than or equal to maximum Claims Resolution limit, if so, then entering step 10433, if it is not, then entering
Enter step 10434.
Step 10433, total amount of settling a claim is defined as to the amount for which loss settled of settlement of insurance claim case to be adjusted.
Step 10434, maximum Claims Resolution limit is defined as to the amount for which loss settled of settlement of insurance claim case to be adjusted.
In the above-mentioned technical solutions, when adjustment according to cost information, it is necessary to according in responsibility managing detailed catalogue
Claims Resolution limit and Claims Resolution ratio are adjusted to general expenses information and add up to obtain Claims Resolution total value.Treated when the Claims Resolution total value exceedes
When adjusting maximum Claims Resolution limit corresponding to settlement of insurance claim case, client is settled a claim according to maximum Claims Resolution limit, otherwise according to
Claims Resolution total value after adjustment is settled a claim to client.So when the number of the cost information of client is excessive, for guarantee insurance
The normal operation of company, fully client can not be settled a claim, therefore just need to formulate phase according to the situation of insuring of each client
The maximum Claims Resolution limit answered.
In addition, insurance company can also be settled a claim according to the ratio of the Claims Resolution total value calculated, for example, according to Claims Resolution total value
70%, 80% or 90% etc. compensated, it is specific settle a claim proportional insurance company can be according to the situation of insuring of client, Huo Zheke
The degree of family loss of personal property is set.
If insurance company is according to the Claims Resolution ratio of the degree setting of client's loss of personal property, carrying out compensating it
Before, first the loss of personal property degree of client is verified, then transferred again corresponding with loss of personal property degree
Claims Resolution ratio, the amount of money obtained after the Claims Resolution ratio is multiplied by according to Claims Resolution total value client is compensated.
In a particular embodiment, the related business rule of comprehensive settlement of insurance claim case, step can be obtained in order to realize
Before 102, in addition to：
Step 102 ', count the corresponding service logic rule of different types of settlement of insurance claim case adjustment process.
Step 102 ", service logic rule is split, obtain multiple business rules.
Step 102 " ', multiple business rules are recorded in the log system pre-established.
Step 102 specifically includes：
With reference to the case feature of settlement of insurance claim case to be adjusted, select to treat from multiple business rules of log system record
Adjustment settlement of insurance claim case needs the target service rule verified.
In the above-mentioned technical solutions, the case feature of settlement of insurance claim case to be adjusted is obtained, according to the case Feature Selection
One or more service logics are regular, screened in the business rule then split out again from the one or more service logic rule
Go out the target service rule corresponding with settlement of insurance claim case to be adjusted.
Wherein service logic rule includes but is not limited at least one following：
The insurance business processing rule of medical class Claims Resolution case, the insurance business processing rule of property class Claims Resolution case, people
Insurance business processing rule, the insurance business processing rule of accident class Claims Resolution case of body injury class Claims Resolution case.
In a particular embodiment, in order to realize that treating adjustment settlement of insurance claim case carries out adjusting the process verified automatically, step
Before rapid 103, method also includes：
Step 103 ', according to the target service of selection rule, configure the corresponding business verification of settlement of insurance claim case to be adjusted
Rule.
Step 103 ", business verification rule is developed and encapsulation process, obtained and business verification rule is corresponding answers
With Program Interfaces API.
Step 103 specifically includes：
Step 1031, conversion process is carried out to Claims Resolution data, generates and treat adjustment verification object.
Step 1032, api interface is transferred, is realized using business verification rule, adjustment verification object is treated and carries out adjustment school
Test.
In the above-mentioned technical solutions, if filter out the target service rule corresponding with settlement of insurance claim case to be adjusted have it is more
It is individual, it is this multiple regularly arranged verification order of target service, and the verification standard with settlement of insurance claim case to be adjusted is set, press
Target service rule is configured according to verification order and verification standard, obtains corresponding business verification rule.Then to this
Business verification rule is developed and encapsulated, and the business verification rule after exploitation and encapsulation is pushed into corresponding application program compiles
Journey interface API.So treat adjustment settlement of insurance claim case carry out adjustment verification when, first by the Claims Resolution data of acquisition
Reason, be processed into be easy to the later stage to be verified treat adjustment verification object.Then corresponding api interface is transferred, obtains and wait to adjust
The corresponding business verification rule of settlement of insurance claim case, and then adjustment verification object is treated according to business verification rule and managed
Calculate verification.It can realize that treating adjustment settlement of insurance claim case carries out Claims Resolution accounting, effectively improves insurance automatically in this way
The timeliness and accuracy of Claims Resolution processing.
For example, can utilize regulation engine DROOLS that service logic rule is split definition, and develop JAVA interface realization
DROOLS rule process code, establishes diary record system, and each business rule after splitting is have recorded in the log system；
In use, these business rules are separated from code by regulation engine DROOLS, allowed users to according to reality
Demand dynamic selects suitable business sub-rule from above-mentioned business sub-rule, the business verification rule required for configuring, then
The business verification rule completed to configuration carries out secondary development and encapsulated, there is provided api interface facilitates system to call, together to system
Shi Dingyi log recordings.
In a particular embodiment, step 1031 specifically includes：
The data related to business verification rule from Claims Resolution extracting data carry out objectification processing, obtain treating adjustment verification
Object.
In the above-mentioned technical solutions, the data used from Claims Resolution extracting data business verification rule, and to the data
Objectification processing (for example, category division, list processing, numerical value extraction etc.) is carried out, is easy to treat reason according to business verification rule
Calculate verification object and carry out automatic adjustment verification.
For example, extract the data such as diagnosis and treatment mechanism, diagnosis and treatment type, hospital's property, bill quantity point from Claims Resolution billing data
Adjustment verification object Zuo Wei not be treated, to treat that adjustment verification object carries out adjustment verification to these；And/or carried from declaration form data
The data such as odd number amount, declaration form insurance kind, unit of insuring of going bail for are respectively as adjustment verification object is treated, to treat adjustment verification to these
Object carries out adjustment verification.Adjustment verification object is treated for what is verified by adjusting, is carried from its corresponding Claims Resolution billing data
The general expenses data of family cottage hospital cost are taken, and are treated as each expense object, corresponding expense is referred to as with expense name
The mark of object；And every responsibility detailed data is extracted from declaration form responsibility detailed data, and it is bright to be treated as each responsibility
Thin object, each responsibility detail object include the contents such as the detailed description of responsibility；In adjustment review process automatically, by expense object
The responsibility that includes with each responsibility detail object of mark it is detailed describe to be matched respectively, find the suitable responsibility of expense object
Detailed object, and then automatic realization, according to the expense in bill, the responsibility matched defined in declaration form is detailed.
As shown in figure 3, in a particular embodiment, in order to meet that business rule is upgraded demand, this method also includes：
Step 102a, business rule is periodically or non-periodically updated；
Accordingly, step 102 specifically includes：
Settlement of insurance claim case to be adjusted is selected to need the target service rule verified from the business rule after renewal.
In the above-mentioned technical solutions, periodically or non-periodically business rule can be updated.The renewal can be addition
New business rule or deletion business rule or modification business rule etc..
, can be according to the interval time of setting, periodically to specific website or server if this is updated to regularly update
Whether search has the more new content of business rule, if so, the business rule for needing to update then is downloaded from website or server,
And local service rule is updated.If again to specific website or service after no, continuing waiting for interval time
Device scans for and repeats such scheme.
Can also be insurance company's system be irregularly updated to business rule according to being actually needed.The renewal can be
Updated manually by staff, button is either updated corresponding to triggering from the specific website of trend or server search phase
The more new content for the business rule answered, is automatically updated.
Further, the specific implementation as Fig. 1 methods, the embodiment of the present application provide a kind of reason of settlement of insurance claim case
Device is calculated, as shown in figure 4, including：Acquiring unit 21, selecting unit 22, verification unit 23 and adjustment unit 24.
Acquiring unit 21, for obtaining the Claims Resolution data of settlement of insurance claim case to be adjusted；
Selecting unit 22, for selecting settlement of insurance claim case to be adjusted to need what is verified from pre-recorded business rule
Target service rule；
Verification unit 23, for according to target service rule and Claims Resolution data, treating adjustment settlement of insurance claim case and being managed
Calculate verification；
Unit 24 is adjusted, if being verified for settlement of insurance claim case to be adjusted by adjusting, according to Claims Resolution data, adjustment is treated
Adjust the amount for which loss settled of settlement of insurance claim case.
As shown in figure 5, in a particular embodiment, Claims Resolution packet contains billing data to be settled a claim and corresponding declaration form data,
Unit 24 is adjusted, is specifically included：
Extraction module 241, for extracting general expenses information from billing data to be settled a claim；And from declaration form extracting data
Every responsibility managing detailed catalogue；
Matching module 242, for general expenses information to be matched respectively with every responsibility managing detailed catalogue；
Module 243 is adjusted, for according to matching result, adjusting the amount for which loss settled of settlement of insurance claim case to be adjusted.
In a particular embodiment, adjustment module 243 specifically includes：
Accumulator module, for reference to the Claims Resolution limit in the responsibility managing detailed catalogue that match with cost information and ratio of settling a claim,
Amount for which loss settled and addition obtain Claims Resolution total amount corresponding to adjustment general expenses information；
Comparing module, for the maximum Claims Resolution limit of declaration form product of settle a claim total amount and settlement of insurance claim case to be adjusted to be entered
Row compares；If total amount of settling a claim is less than or equal to maximum Claims Resolution limit, Claims Resolution total amount is defined as settlement of insurance claim to be adjusted
The amount for which loss settled of case；If total amount of settling a claim is more than maximum Claims Resolution limit, maximum Claims Resolution limit is defined as to treat adjustment insurance
The amount for which loss settled for case of settling a claim.
In a particular embodiment, device also includes：
Split cells is counted, for counting the corresponding service logic rule of different types of settlement of insurance claim case adjustment process
Then；Service logic rule is split, obtains multiple business rules；Multiple business are recorded in the log system pre-established
Rule；
Selecting unit 22, the case feature with reference to settlement of insurance claim case to be adjusted is additionally operable to, from the more of log system record
Settlement of insurance claim case to be adjusted is selected to need the target service rule verified in individual business rule.
In a particular embodiment, device also includes：
Dispensing unit, for the target service rule according to selection, configure the corresponding business of settlement of insurance claim case to be adjusted
Verification rule；
Exploitation and encapsulation unit, for being developed and encapsulation process to business verification rule, obtain and business verification is advised
Then corresponding application programming interface API；
Verification unit 23, it is additionally operable to carry out conversion process to Claims Resolution data, generates and treat adjustment verification object；API is transferred to connect
Mouthful, realize using business verification rule, treat adjustment verification object and carry out adjustment verification.
In a particular embodiment, verification unit 23, it is additionally operable to related to business verification rule from Claims Resolution extracting data
Data carry out objectification processing, obtain treating adjustment verification object.
As shown in fig. 6, in a particular embodiment, device also includes：
Updating block 25, for periodically or non-periodically being updated to business rule；
Selecting unit 22, it is additionally operable to select settlement of insurance claim case to be adjusted to need what is verified from the business rule after renewal
Target service rule.
Based on method shown in above-mentioned Fig. 1-3, accordingly, the embodiment of the present application additionally provides a kind of storage device, deposits thereon
Computer program is contained, step corresponding to method shown in Fig. 1-3 is realized when program is executed by processor.
One kind is additionally provided based on method shown in above-mentioned Fig. 1-3 and the embodiment of Fig. 4-6 shown devices, the embodiment of the present application
The entity apparatus of settlement of insurance claim case adjustment, as shown in fig. 7, comprises storage device 32 and processor 31, wherein storage device 32
It is arranged at processor 31 in bus 33.
Storage device 32, for storing computer program；
Processor 31, for performing computer program to realize step corresponding to method shown in Fig. 1-3.
By the above-mentioned technical proposal of the application, entirely the adjustment checking procedure of settlement of insurance claim case to be adjusted all is automatic
Complete without manually participating in, can so save substantial amounts of human resources, save the time of adjustment verification, can avoid due to
The error brought manually is participated in, reduces error rate, effectively improves the accuracy of adjustment verification.
Through the above description of the embodiments, those skilled in the art can be understood that the application can lead to
Hardware realization is crossed, the mode of necessary general hardware platform can also be added by software to realize.Based on such understanding, this Shen
Technical scheme please can be embodied in the form of software product, and the software product can be stored in a non-volatile memories
In medium (can be CD-ROM, USB flash disk, mobile hard disk etc.), including some instructions are causing a computer equipment (can be
Personal computer, server, or network equipment etc.) perform each implement scene of the application described in method.
It will be appreciated by those skilled in the art that accompanying drawing is a schematic diagram for being preferable to carry out scene, module in accompanying drawing or
Flow is not necessarily implemented necessary to the application.
It will be appreciated by those skilled in the art that the module in device in implement scene can be described according to implement scene into
Row is distributed in the device of implement scene, can also carry out one or more dresses that respective change is disposed other than this implement scene
In putting.The module of above-mentioned implement scene can be merged into a module, can also be further split into multiple submodule.
Above-mentioned the application sequence number is for illustration only, does not represent the quality of implement scene.
Disclosed above is only several specific implementation scenes of the application, and still, the application is not limited to this, Ren Heben
What the technical staff in field can think change should all fall into the protection domain of the application.
Claims (10)
- A kind of 1. adjustment method of settlement of insurance claim case, it is characterised in that methods described includes：Obtain the Claims Resolution data of settlement of insurance claim case to be adjusted；Settlement of insurance claim case to be adjusted described in selection needs the target service rule verified from pre-recorded business rule；According to the regular and described Claims Resolution data of the target service, adjustment verification is carried out to the settlement of insurance claim case to be adjusted；If the settlement of insurance claim case to be adjusted verifies by adjusting, according to the Claims Resolution data, treat that adjustment is protected described in adjustment The amount for which loss settled of danger Claims Resolution case.
- 2. according to the method for claim 1, it is characterised in that the Claims Resolution packet is containing billing data to be settled a claim and accordingly Declaration form data, according to the Claims Resolution data, the amount for which loss settled of settlement of insurance claim case to be adjusted, is specifically included described in adjustment：General expenses information is extracted from the billing data to be settled a claim；AndFrom the declaration form extracting data items responsibility managing detailed catalogue；The general expenses information is matched respectively with every responsibility managing detailed catalogue；According to matching result, the amount for which loss settled of settlement of insurance claim case to be adjusted described in adjustment.
- 3. according to the method for claim 2, it is characterised in that it is described according to matching result, adjustment insurance is treated described in adjustment The amount for which loss settled for case of settling a claim, is specifically included：With reference to the Claims Resolution limit in the responsibility managing detailed catalogue matched with cost information and Claims Resolution ratio, general expenses information pair is adjusted The amount for which loss settled and addition answered obtain total amount of settling a claim；The Claims Resolution total amount is compared with the maximum Claims Resolution limit of the declaration form product of the settlement of insurance claim case to be adjusted；If the Claims Resolution total amount is less than or equal to the maximum limit of settling a claim, the Claims Resolution total amount is defined as described treat Adjust the amount for which loss settled of settlement of insurance claim case；If the Claims Resolution total amount is more than the maximum limit of settling a claim, the maximum limit of settling a claim is defined as described waiting to adjust The amount for which loss settled of settlement of insurance claim case.
- 4. according to the method for claim 1, it is characterised in that described to be treated from pre-recorded business rule described in selection Before the target service rule that adjustment settlement of insurance claim case needs verify, in addition to：Count the corresponding service logic rule of different types of settlement of insurance claim case adjustment process；The service logic rule is split, obtains multiple business rules；The multiple business rule is recorded in the log system pre-established；The settlement of insurance claim case to be adjusted described in selection from pre-recorded business rule needs target service verified Rule, specifically include：The case feature of settlement of insurance claim case to be adjusted with reference to described in, is selected from multiple business rules of log system record Select the target service rule that the settlement of insurance claim case to be adjusted needs to verify.
- 5. according to the method for claim 4, it is characterised in that according to the regular and described Claims Resolution data of the target service, Before carrying out adjustment verification to the settlement of insurance claim case to be adjusted, methods described also includes：According to the target service of selection rule, the corresponding business verification rule of settlement of insurance claim case to be adjusted described in configuration；Business verification rule is developed and encapsulation process, obtained and the corresponding application program of business verification rule DLL API；According to the regular and described Claims Resolution data of the target service, adjustment verification is carried out to the settlement of insurance claim case to be adjusted, Specifically include：Conversion process is carried out to the Claims Resolution data, generates and treats adjustment verification object；The api interface is transferred, is realized using business verification rule, treats that adjustment verification object carries out adjustment school to described Test.
- 6. according to the method for claim 5, it is characterised in that conversion process is carried out to the Claims Resolution data, generates and waits to manage Verification object is calculated, is specifically included：The data related to business verification rule from the Claims Resolution extracting data carry out objectification processing, obtain waiting to adjust Verify object.
- 7. according to the method described in any one of claim 1 to 6, it is characterised in that methods described also includes：The business rule is periodically or non-periodically updated；The settlement of insurance claim case to be adjusted described in selection from pre-recorded business rule needs the target service rule verified Then, specifically include：Settlement of insurance claim case to be adjusted described in selection needs the target service rule verified from the business rule after renewal.
- 8. a kind of adjustment device of settlement of insurance claim case, it is characterised in that described device includes：Acquiring unit, for obtaining the Claims Resolution data of settlement of insurance claim case to be adjusted；Selecting unit, the mesh for needing to verify for settlement of insurance claim case to be adjusted described in the selection from pre-recorded business rule Mark business rule；Verification unit, for according to the regular and described Claims Resolution data of the target service, to the settlement of insurance claim case to be adjusted Carry out adjustment verification；Unit is adjusted, if being verified for the settlement of insurance claim case to be adjusted by adjusting, according to the Claims Resolution data, adjustment The amount for which loss settled of the settlement of insurance claim case to be adjusted.
- 9. a kind of storage device, is stored thereon with computer program, it is characterised in that is realized when described program is executed by processor The adjustment method of settlement of insurance claim case described in any one of claim 1 to 7.
- A kind of 10. adjustment device of settlement of insurance claim case, it is characterised in that described device includes storage device and processor,The storage device, for storing computer program；The processor, for performing the computer program to realize the settlement of insurance claim case described in any one of claim 1 to 7 The adjustment method of part.
Priority Applications (2)
| Application Number | Priority Date | Filing Date | Title |
|---|---|---|---|
| CN201711111127.0A CN107705211A (en) | 2017-11-10 | 2017-11-10 | A kind of adjustment method and apparatus of settlement of insurance claim case |
| PCT/CN2018/074625 WO2019090986A1 (en) | 2017-11-10 | 2018-01-30 | Adjustment method and device for insurance claim settlement case |
Applications Claiming Priority (1)
| Application Number | Priority Date | Filing Date | Title |
|---|---|---|---|
| CN201711111127.0A CN107705211A (en) | 2017-11-10 | 2017-11-10 | A kind of adjustment method and apparatus of settlement of insurance claim case |
Publications (1)
| Publication Number | Publication Date |
|---|---|
| CN107705211A true CN107705211A (en) | 2018-02-16 |
Family
ID=61179280
Family Applications (1)
| Application Number | Title | Priority Date | Filing Date |
|---|---|---|---|
| CN201711111127.0A Pending CN107705211A (en) | 2017-11-10 | 2017-11-10 | A kind of adjustment method and apparatus of settlement of insurance claim case |
Country Status (2)
| Country | Link |
|---|---|
| CN (1) | CN107705211A (en) |
| WO (1) | WO2019090986A1 (en) |
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| CN108320233A (en) * | 2018-02-26 | 2018-07-24 | 平安科技（深圳）有限公司 | Bill annotation generation method and device and computer-readable storage medium |
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| CN114298845A (en) * | 2021-11-29 | 2022-04-08 | 泰康保险集团股份有限公司 | Method and device for processing claim settlement bills |
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| CN115328943A (en) * | 2022-01-10 | 2022-11-11 | 中国银联股份有限公司 | Data processing method and device |
| CN115330388A (en) * | 2022-06-29 | 2022-11-11 | 北京健康之家科技有限公司 | A business settlement processing method, device, storage medium and electronic device |
| CN117273666A (en) * | 2023-11-21 | 2023-12-22 | 太平金融科技服务(上海)有限公司深圳分公司 | An automatic claims settlement method, electronic device and storage medium |
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| WO2019090986A1 (en) | 2019-05-16 |
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