A health insurance loss assessment data processing method, server and computer readable medium

Abstract

The embodiment of the present application discloses a method, server and computer-readable medium for processing health insurance loss assessment data, which involves loss assessment data processing, wherein the method includes: receiving a health insurance claim request from a user terminal, and obtaining policy information from a database according to the insured identity information included in the health insurance claim request; generating a loss assessment information acquisition request including a loss assessment information list according to the policy information and the claim information included in the health insurance claim request, and sending the acquisition request to the third-party platform; receiving the loss assessment information fed back by the third-party platform in response to the loss assessment information acquisition request; and performing loss assessment processing on the above-mentioned insurance accident according to the loss assessment information sent by the third-party platform and the policy information. Through the embodiment of the present application, the work efficiency of health insurance claim loss assessment can be effectively improved, labor costs can be saved, loss assessment standards can be unified, and deviations caused by human subjective factors in the loss assessment process can be avoided.

Description

Technical Field

[0001] The present application relates to the field of insurance claims technology, and in particular to a health insurance loss assessment data processing method, server and computer-readable medium. Background Art

[0002] With the continuous development of social economy and the improvement of people's material living standards, people are paying more and more attention to the health of themselves and their families, and the investment in health is also increasing. For example, investment in health insurance. In order to protect their own health, most people choose to buy themselves a health insurance to make up for the economic losses caused by major diseases, medical treatment, etc. For insurance, users and insurance companies are more concerned about insurance claims. In the claims process, the more important link is the loss assessment.

[0003] However, in the traditional health insurance claims assessment process, it is generally handled manually by corresponding claims specialists according to the corresponding insurance claims terms or rules. The processing procedures are complicated and inefficient. In addition, different claims specialists have different understandings of the claims terms, which may cause inconsistent claims standards. It is difficult to avoid deviations in the loss assessment process caused by human subjective factors, which brings great inconvenience to insurance claims. Summary of the invention

[0004] The embodiment of the present application provides a method for processing health insurance loss assessment data, which can effectively improve the work efficiency of health insurance claims and loss assessment, save labor costs, unify loss assessment standards, and avoid deviations caused by human subjective factors.

[0005] In a first aspect, an embodiment of the present application provides a method for processing health insurance loss assessment data, the method comprising:

[0006] Receiving a health insurance claim request for an insurance accident from a user terminal, responding to the health insurance claim request, and acquiring policy information of the health insurance type purchased by the insured from a database according to the insured's identity information included in the health insurance claim request;

[0007] Generate a request for obtaining damage information including a list of damage information according to the insurance policy information and the claim information included in the health insurance claim request, and send the request to the third-party platform;

[0008] Receiving damage information sent by the third-party platform, where the damage information sent by the third-party platform is information obtained by the third-party platform from a third-party platform database according to the damage information list;

[0009] The above-mentioned insurance accident is assessed for damage based on the damage information sent by the third-party platform and the insurance policy information.

[0010] Optionally, the claim settlement information also includes the time of occurrence of the insurance accident;

[0011] After acquiring the policy information of the health insurance type purchased by the insured from the database according to the insured's identity information included in the health insurance claim request, the method further includes:

[0012] Determining whether the time of occurrence of the insurance accident is within the insurance period included in the insurance policy information;

[0013] If the time when the insurance accident occurs is within the insurance period included in the policy information, then determining whether the time when the insurance accident occurs is after the waiting period included in the policy information;

[0014] If the time when the insurance accident occurs is after the waiting period included in the policy information, the step of generating a request for obtaining damage assessment information from a third-party platform for the insurance accident based on the policy information and the claim information included in the health insurance claim request is executed.

[0015] Optionally, the claim settlement information includes the cause of the insurance accident;

[0016] The generating a request for obtaining damage information including a damage information list according to the insurance policy information and the claim information included in the health insurance claim request comprises:

[0017] Performing semantic recognition on the cause of the insurance accident to obtain a first semantic recognition result;

[0018] Determining, according to the first semantic recognition result, the insurance liability in the insurance policy information corresponding to the first semantic recognition result;

[0019] Generate a list of damage assessment information according to the mapping relationship between insurance liability and damage assessment information and the insurance liability in the policy information corresponding to the first semantic recognition result;

[0020] The acquisition request for obtaining the damage information from the third-party platform for the insurance accident is generated according to the mapping relationship between the damage information and the third-party platform and the damage information list, and the acquisition request includes the damage information list.

[0021] Optionally, after receiving the damage assessment information sent by the third-party platform and before performing damage assessment processing on the insurance accident according to the damage assessment information sent by the third-party platform and the insurance policy information, the method further includes:

[0022] Performing semantic recognition on text information in the damage information sent by the third-party platform to obtain a second semantic recognition result, and performing image recognition on image information in the damage information sent by the third-party platform to obtain an image recognition result;

[0023] The second semantic recognition result, the image recognition result and other information in the damage information sent by the third-party platform except text information and image information are structured according to a preset structured format to obtain damage data.

[0024] Optionally, the performing loss assessment on the insurance accident according to the loss assessment information and the insurance policy information includes:

[0025] Obtaining loss assessment rules from a rule base according to a mapping relationship between insurance liability and loss assessment rules and the insurance liability corresponding to the first semantic recognition result in the policy information, wherein the loss assessment rules include medical expense calculation rules and third-party expense calculation rules, and the medical expense calculation rules include at least one of hospitalization expense calculation rules, outpatient emergency expense calculation rules, and outpatient surgery expense calculation rules;

[0026] Calculate the medical expenses and third-party expenses of the insured person according to the loss assessment data and the loss assessment rules, wherein the medical expenses include at least one of hospitalization expenses, outpatient emergency expenses, and outpatient surgery expenses;

[0027] The claim amount that the insurer needs to pay in the insurance accident is calculated based on the insured's medical expenses, the insured's third-party expenses, and the deductible information and compensation ratio information contained in the policy information.

[0028] Optionally, the calculating the claim amount that the insurer needs to pay in the insurance accident according to the medical expenses of the insured, the third-party expenses of the insured, and the deductible information and the compensation ratio information included in the policy information includes:

[0029] Calculating the deductible amount in the medical expenses according to the deductible amount information included in the insurance policy information;

[0030] The final cost obtained by deducting the deductible and the third-party costs from the medical expenses and multiplying it by the compensation ratio in the compensation ratio information is determined as the claim amount.

[0031] Optionally, after performing loss assessment on the insurance accident according to the loss assessment information sent by the third-party platform and the insurance policy information, the method further includes:

[0032] generating a claim expense list based on the loss assessment result of the insurance accident, and generating feedback information based on the claim expense list;

[0033] Sending the feedback information to the user terminal.

[0034] In a second aspect, an embodiment of the present application provides a server, the server comprising:

[0035] A receiving unit, configured to receive a health insurance claim request for an insurance accident from a user terminal;

[0036] A first acquisition unit, configured to respond to the health insurance claim settlement request and acquire, from a database, policy information of the health insurance type purchased by the insured according to the insured identity information included in the health insurance claim settlement request;

[0037] A generating unit, configured to generate a request for obtaining damage information including a damage information list according to the insurance policy information and the claim information included in the health insurance claim request;

[0038] A sending unit, configured to send the acquisition request to the third-party platform;

[0039] The receiving unit is further used to receive the damage information fed back by the third-party platform in response to the damage information acquisition request, and the damage information sent by the third-party platform is information obtained by the third-party platform from the third-party platform database according to the damage information list and the insured's identity information;

[0040] The claims settlement unit is used to carry out loss assessment processing on the above-mentioned insurance accident based on the loss assessment information sent by the third-party platform and the insurance policy information.

[0041] Optionally, the claim settlement information also includes the time of occurrence of the insurance accident;

[0042] The server also includes:

[0043] A first judgment unit is used to judge whether the time of occurrence of the insurance accident is within the insurance period included in the insurance policy information; if the time of occurrence of the insurance accident is within the insurance period included in the insurance policy information, then judge whether the time of occurrence of the insurance accident is after the waiting period included in the insurance policy information;

[0044] The generating unit is used to execute the step of generating a request for obtaining damage assessment information from a third-party platform for the insurance accident based on the insurance policy information and the claim information included in the health insurance claim request if the time when the insurance accident occurs is after the waiting period included in the policy information.

[0045] Optionally, the claim settlement information includes the cause of the insurance accident;

[0046] The generating unit comprises:

[0047] A first recognition unit is used to perform semantic recognition on the cause of the insurance accident to obtain a first semantic recognition result;

[0048] A second judgment unit, configured to judge, according to the first semantic recognition result, the insurance liability in the insurance policy information corresponding to the first semantic recognition result;

[0049] The generation unit is also used to generate a list of damage information based on the mapping relationship between insurance liability and damage information and the insurance liability in the policy information corresponding to the first semantic recognition result; and generate an acquisition request for obtaining damage information from the third-party platform for the insurance accident based on the mapping relationship between the damage information and the third-party platform and the damage information list, wherein the acquisition request includes a list of damage information.

[0050] Optionally, the server further includes:

[0051] A second recognition unit is used to perform semantic recognition on the text information in the damage information sent by the third-party platform to obtain a second semantic recognition result, and perform image recognition on the image information in the damage information sent by the third-party platform to obtain an image recognition result;

[0052] A processing unit is used to structure the second semantic recognition result, the image recognition result and other information in the damage information sent by the third-party platform except text information and image information according to a preset structured format to obtain damage data.

[0053] Optionally, the claims settlement unit includes:

[0054] a second acquisition unit, configured to acquire a loss assessment rule from a rule base according to a mapping relationship between insurance liability and loss assessment rule and the insurance liability corresponding to the first semantic recognition result in the policy information, wherein the loss assessment rule includes a medical expense calculation rule and a third-party expense calculation rule, and the medical expense calculation rule includes at least one of a hospitalization expense calculation rule, an outpatient emergency expense calculation rule, and an outpatient surgery expense calculation rule;

[0055] A calculation unit, used to calculate the medical expenses and third-party expenses of the insured according to the loss assessment data and the loss assessment rules, wherein the medical expenses include at least one of hospitalization expenses, outpatient emergency expenses, and outpatient surgery expenses;

[0056] The calculation unit is also used to calculate the claim amount that the insurer needs to pay in the insurance accident based on the insured's medical expenses, the insured's third-party expenses, and the deductible information and compensation ratio information contained in the policy information.

[0057] Optionally, the calculation unit is used to calculate the deductible in the medical expenses based on the deductible information contained in the policy information; and determine the final cost obtained by deducting the deductible and the third-party costs from the medical expenses and multiplying it by the compensation ratio in the compensation ratio information as the claim amount.

[0058] Optionally, the server further includes:

[0059] A feedback unit, configured to generate a claim expense list according to the result of the loss assessment process for the insurance accident, and to generate feedback information according to the claim expense list;

[0060] The sending unit is configured to send the feedback information to the user terminal.

[0061] In a third aspect, an embodiment of the present application provides another server, comprising a processor, a memory and a communication module, wherein the memory is used to store program code, and the processor is used to call the program code to execute the method of the above-mentioned first aspect and any optional method thereof.

[0062] In a fourth aspect, an embodiment of the present application provides a computer-readable storage medium, wherein the computer storage medium stores a computer program, wherein the computer program includes program instructions, and when the program instructions are executed by a processor, the processor executes the method of the above-mentioned first aspect and any optional method thereof.

[0063] The embodiment of the present application receives the health insurance claim request sent by the applicant, and then determines to file a case based on the above health insurance claim request; then obtains the loss assessment information of the insurance accident based on the above health insurance claim request; and finally performs loss assessment based on the loss assessment information of the above insurance accident and the health insurance loss assessment rules. Through the embodiment of the present application, the work efficiency of health insurance claim loss assessment can be effectively improved, labor costs can be saved, loss assessment standards can be unified, and deviations caused by human subjective factors in the loss assessment process can be avoided. BRIEF DESCRIPTION OF THE DRAWINGS

[0064] In order to more clearly illustrate the technical solutions of the embodiments of the present application, the following briefly introduces the drawings required for describing the embodiments.

[0065] Figure 1 It is a schematic flow chart of a method for processing health insurance loss assessment data provided by an embodiment of the present application;

[0066] Figure 2 It is a schematic flow chart of another health insurance loss assessment data processing method provided in an embodiment of the present application;

[0067] Figure 3 is a schematic block diagram of a server provided in an embodiment of the present application;

[0068] Figure 4 is a schematic block diagram of a device provided in an embodiment of the present application;

[0069] Figure 5 It is a schematic diagram of a server structure provided in an embodiment of the present application. DETAILED DESCRIPTION

[0070] The technical solutions in the embodiments of the present application will be clearly and completely described below in conjunction with the drawings in the embodiments of the present application.

[0071] It should be understood that when used in this specification and the appended claims, the terms "include" and "comprises" indicate the presence of described features, integers, steps, operations, elements and / or components, but do not exclude the presence or addition of one or more other features, integers, steps, operations, elements, components and / or combinations thereof.

[0072] It should also be understood that the terms used in this application specification are only for the purpose of describing specific embodiments and are not intended to limit the application. As used in this application specification and the appended claims, unless the context clearly indicates otherwise, the singular forms "a", "an" and "the" are intended to include plural forms.

[0073] It should be further understood that the term “and / or” used in the specification and appended claims refers to any and all possible combinations of one or more of the associated listed items, and includes these combinations.

[0074] As used in this specification and the appended claims, the term "if" may be interpreted as "when" or "upon" or "in response to determining" or "in response to detecting," depending on the context. Similarly, the phrases "if it is determined" or "if [described condition or event] is detected" may be interpreted as meaning "upon determination" or "in response to determining" or "upon detection of [described condition or event]" or "in response to detecting [described condition or event]," depending on the context.

[0075] Health insurance, also known as "health insurance", refers to personal insurance in which the insurer pays the insured when the insured becomes ill. The scope of payment for health insurance usually includes medical expenses, income loss, funeral expenses, and living expenses for the surviving family. This type of insurance is often co-sponsored with injury insurance, and sometimes with life insurance. In order to prevent moral hazard, when applying for health insurance, the insurer usually stipulates a trial period. The insurer is responsible for compensation for losses caused by illness to the insured after this period.

[0076] See also Figure 1 , Figure 1is a schematic flow chart of a method for processing health insurance loss assessment data provided by an embodiment of the present application, such as Figure 1 As shown, the method may include:

[0077] 101: receiving a health insurance claim request for an insurance accident from a user terminal, responding to the health insurance claim request, and acquiring policy information of the health insurance type purchased by the insured from a database according to the insured's identity information included in the health insurance claim request.

[0078] Among them, the above-mentioned health insurance claim request includes the insured's identity information and claim information, and the above-mentioned claim information includes the cause of the insurance accident, the time of occurrence of the insurance accident, etc.

[0079] In an embodiment of the present application, when the above-mentioned insured person has a health insurance accident (for example, the accident person is accidentally injured and treated in the hospital), the applicant (which may be the insured person himself or the insured person's family or relatives) logs in to the website or App of the health insurance claim platform through a wired or wireless terminal device to initiate a claim request to the health insurance claim platform. After the health insurance claim platform receives the above-mentioned health insurance claim request, the health insurance claim platform obtains the policy information of the health insurance type insured by the above-mentioned insured person from the database based on the identity information of the insured person in the above-mentioned health insurance claim request, and then determines whether the above-mentioned claim request meets the conditions for the health insurance claim application based on the policy information of the health insurance type insured by the above-mentioned insured person and the time of occurrence of the insurance accident. If the conditions are met, continue to execute step 102.

[0080] Among them, the above-mentioned insurance policy information includes all health insurance types insured by the above-mentioned insured, as well as information such as the insurance period and insured amount of each insurance type and the insurance terms corresponding to the health insurance type (such as the insurance liability assumed by the insurer, the claims information and procedures required for each insurance liability when making a claim, and some definitions of terms, etc.).

[0081] 102: Generate a request for obtaining damage information including a damage information list based on the insurance policy information and the claim information included in the health insurance claim request, and send the request to the third-party platform.

[0082] In an embodiment of the present application, after the above-mentioned health insurance claims platform accepts the above-mentioned health insurance claims request and determines that the above-mentioned health insurance claims request meets the health insurance claims application conditions, the above-mentioned health insurance claims platform generates an acquisition request for the above-mentioned insurance accident to obtain the damage information from the third-party platform based on the above-mentioned policy information and the claims information included in the above-mentioned health insurance claims request, and then sends the above-mentioned acquisition request to the above-mentioned third-party platform, wherein the above-mentioned acquisition request includes a list of damage information. In addition, the above-mentioned third-party platforms may include medical platforms, other insurance companies, administrative service platforms, traffic management platforms, enterprise management platforms, etc. It is understandable that since the above-mentioned damage information may come from different third-party platforms, multiple acquisition requests may be generated in order to obtain damage information from multiple third-party platforms.

[0083] Specifically, when the above-mentioned health insurance claims platform accepts the above-mentioned health insurance claims request and determines that the above-mentioned health insurance claims request meets the health insurance claims application conditions, the above-mentioned health insurance claims platform performs semantic recognition on the cause of the insurance accident and obtains the first semantic recognition result. Then the above-mentioned health insurance claims platform determines the insurance liability corresponding to the above-mentioned first semantic recognition result in the above-mentioned policy information based on the above-mentioned first semantic recognition result, and generates a list of damage information based on the mapping relationship between insurance liability and damage information and the insurance liability corresponding to the above-mentioned first semantic recognition result in the above-mentioned policy information. That is, according to the cause of the insurance accident, determine which one or more insurance liabilities in the policy information the insurance accident corresponds to, and then determine which damage information is needed for these insurance liabilities to be damaged during the claim damage. Then, the above-mentioned health insurance claims platform generates the above-mentioned acquisition request for obtaining damage information from the third-party platform for the above-mentioned insurance accident based on the mapping relationship between the damage information and the third-party platform and the above-mentioned damage information list, and sends the above-mentioned acquisition request to the third-party platform, wherein the above-mentioned acquisition request includes the damage information list of the damage information that needs to be obtained from the third-party platform and the identity information of the insured.

[0084] In the embodiment of the present application, the above-mentioned health insurance accident loss assessment information refers to information that can determine or evaluate how much insurance money the insurer needs to pay (pay) to the insured in the above-mentioned health insurance accident.

[0085] In an embodiment of the present application, the above-mentioned loss assessment information includes: medical expense information and third-party expense information, wherein the medical expense information includes outpatient emergency expense information, hospitalization expense information, and outpatient surgery expense information; the third-party expense information includes social medical insurance information and third-party subsidy information.

[0086] Among them, the above-mentioned outpatient expense information may include doctor's consultation fees, registration fees, treatment fees, examination and testing fees, drug fees, etc.; the above-mentioned inpatient medical expense information includes bed fees, accompanying bed fees, intensive care unit bed fees, nursing fees, meal fees, examination and testing fees, treatment fees, drug fees, doctor fees, surgery fees, ambulance usage fees, etc.; the above-mentioned social medical insurance expense information includes compensation obtained from social medical insurance; the above-mentioned third-party expenses refer to the unit or platform that obtains compensation in the insurance accident from other than the insured insurance company and social medical insurance. For example, the compensation obtained by the accident victim from his own company or from other insurance companies are all third-party expenses.

[0087] 103: receiving the damage information fed back by the third-party platform in response to the damage information acquisition request, the damage information sent by the third-party platform is information acquired by the third-party platform from the third-party platform database according to the damage information list.

[0088] In an embodiment of the present application, when the third-party platform receives the acquisition request sent by the health insurance claims platform, the third-party platform obtains the damage information listed in the damage information list from the database of the third-party platform based on the insured's identity information and the damage information list in the above acquisition request, and then packages the acquired damage information and sends it to the health insurance claims platform.

[0089] 104: Conduct loss assessment for the above insurance accident based on the loss assessment information sent by the above third-party platform and the above insurance policy information.

[0090] In an embodiment of the present application, after the above-mentioned health insurance claims platform obtains the above-mentioned health insurance loss assessment information, the health insurance claims platform will conduct loss assessment processing on the above-mentioned insurance accident based on the loss assessment information sent by the above-mentioned third-party platform and the information contained in the above-mentioned policy information.

[0091] Specifically, when the above-mentioned health insurance claim platform obtains the above-mentioned health insurance loss information, the health insurance claim platform pre-processes the above-mentioned loss information to obtain loss data that can be recognized by the system, and then the health insurance claim platform obtains the loss rule from the rule library according to the mapping relationship between the insurance liability and the loss rule and the insurance liability corresponding to the above-mentioned first semantic recognition result in the above-mentioned policy information; wherein the above-mentioned loss rule includes medical expense calculation rules and third-party expense calculation rules, and the above-mentioned medical expense calculation rules include at least one of the hospitalization expense calculation rules, outpatient emergency expense calculation rules, and outpatient surgery expense calculation rules. Then, the above-mentioned health insurance claim platform calculates the medical expenses and third-party expenses of the above-mentioned insured according to the above-mentioned loss data and the above-mentioned loss rules; wherein the above-mentioned medical expenses include at least one of the hospitalization expenses, outpatient emergency expenses, and outpatient surgery expenses. Finally, the health insurance claim platform calculates the claim amount that the insurer needs to pay in the above-mentioned insurance accident based on the above-mentioned insured's medical expenses, the above-mentioned insured's third-party expenses, and the deductible information and compensation ratio information contained in the above-mentioned policy information.

[0092] The above health insurance claims platform calculates the claim amount that the insurer needs to pay in the above insurance accident based on the above insured's medical expenses, the above insured's third-party expenses, and the deductible information and compensation ratio information contained in the above policy information. The above claim amount can be calculated as follows:

[0093] ;

[0094] In the above formula, S is the above-mentioned claim amount, M is the medical expenses actually paid by the above-mentioned insured, E is the medical deductible agreed in the policy information, T is the subsidy obtained by the insured from a third party, and P is the compensation ratio agreed in the policy information.

[0095] As an optional implementation, the above-mentioned health insurance claims platform pre-processes the above-mentioned damage information to obtain damage data that can be recognized by the system, specifically including: the health claims platform performs semantic recognition on the text information in the damage information sent by the third-party platform to obtain a second semantic recognition result, and performs image recognition on the image information in the damage information sent by the third-party platform to obtain an image recognition result; then the second semantic recognition result, the image recognition result and other information in the damage information sent by the third-party platform except the text information and the image information are structured according to a preset structured format to obtain the damage data.

[0096] Specifically, after the above-mentioned claims platform obtains the damage assessment information of the above-mentioned insurance accident, the above-mentioned claims platform verifies and corrects the above-mentioned damage assessment information. Then the above-mentioned claims platform performs semantic recognition on the text information in the above-mentioned damage assessment information to obtain a semantic recognition result that can be recognized by the claims processing module of the claims platform. For example, Neuro-Linguistic Programming (NLP) technology can be used to perform semantic recognition on the traffic liability determination letter. The above-mentioned claims platform performs image recognition on the image information in the above-mentioned damage assessment information to obtain an image recognition result that can be recognized by the claims processing module of the claims platform. Finally, the above-mentioned semantic recognition structure, image recognition results and other information in the above-mentioned damage assessment information except text information and image information are structured according to a preset structured format to obtain claim data that can be recognized by the claims processing system.

[0097] It can be seen that the embodiment of the present application receives the health insurance claim request sent by the applicant through the health insurance claim platform, and then obtains the policy information of the health insurance type insured by the insured from the database, and determines the loss assessment information required for the above-mentioned insurance accident to be processed based on the above-mentioned health insurance claim request and policy information, as well as the third-party platform for obtaining this information. The health insurance claim platform then initiates a request to obtain the loss assessment information to the third-party platform, and receives the loss assessment information sent by the third-party platform. Finally, the health insurance claim platform processes the above-mentioned insurance accident based on the loss assessment information sent by the third-party platform and the above-mentioned policy information. Through the embodiment of the present application, the work efficiency of health insurance claims and loss assessment can be effectively improved, labor costs can be saved, loss assessment standards can be unified, and deviations caused by human subjective factors in the loss assessment process can be avoided.

[0098] See also Figure 2 , Figure 2 is a schematic flow chart of another method for processing health insurance loss assessment data provided by an embodiment of the present application, such as Figure 2 As shown, the method may include:

[0099] 201: receiving a health insurance claim request for an insurance accident from a user terminal, responding to the health insurance claim request, and acquiring policy information of the health insurance type purchased by the insured from a database according to the insured's identity information included in the health insurance claim request.

[0100] Among them, the above-mentioned health insurance claim request includes the insured's identity information and claim information, and the above-mentioned claim information includes information such as the cause of the insurance accident and the time of occurrence of the insurance accident.

[0101] 202: Determine whether the occurrence time of the above insurance accident is within the insurance period included in the above insurance policy information.

[0102] In an embodiment of the present application, if the health insurance claim platform determines that the time of occurrence of the above-mentioned insurance accident is within the insurance period included in the above-mentioned policy information, step 203 is executed; if it is determined that the time of occurrence of the above-mentioned insurance accident is not within the insurance period included in the above-mentioned policy information, the process ends, or a feedback message is generated and sent to the user terminal to remind the user that the time of occurrence of the insurance accident is not within the reporting period and the claim application cannot be made.

[0103] 203: Determine whether the time when the above insurance accident occurs is after the waiting period included in the above insurance policy information.

[0104] In an embodiment of the present application, if the health insurance claim platform determines that the time when the above-mentioned insurance accident occurred is after the waiting period included in the above-mentioned policy information, it means that the above-mentioned health insurance claim request meets the health insurance claim application conditions, and continue to execute step 204; if the health insurance claim platform determines that the time when the above-mentioned insurance accident occurred is within the waiting period included in the above-mentioned policy information, it ends, or generates a feedback message and sends the feedback message to the user terminal to remind the user that the time of occurrence of the insurance accident is within the waiting period and the claim application cannot be made.

[0105] 204: Perform semantic recognition on the cause of the insurance accident to obtain a first semantic recognition result; and determine the insurance liability corresponding to the first semantic recognition result in the insurance policy information according to the first semantic recognition result.

[0106] In an embodiment of the present application, when the health insurance claims platform determines that the claim request for the above-mentioned insurance accident meets the claim application conditions, it performs semantic recognition processing on the cause of the insurance accident filled in by the applicant contained in the claim request, and obtains a first recognition result, so that the health insurance claims platform can determine the insurance liability that matches the first semantic recognition result in the above-mentioned policy information based on the first recognition result. It can be understood that in an embodiment of the present application, a health insurance type may include one or more insurance liabilities and be recorded in the policy information. An insurance accident can correspond to one or more insurance liabilities in a health insurance type, and different insurance liabilities can have designated loss assessment information to perform loss assessment processing on the insurance accident.

[0107] 205: Generate a list of damage assessment information based on the mapping relationship between insurance liability and damage assessment information and the insurance liability in the above-mentioned policy information corresponding to the above-mentioned first semantic recognition result; and generate the above-mentioned request for obtaining the above-mentioned damage assessment information from the third-party platform for the above-mentioned insurance accident based on the mapping relationship between the damage assessment information and the third-party platform and the above-mentioned damage assessment information list.

[0108] In an embodiment of the present application, a mapping relationship between insurance liability and damage assessment information, as well as a mapping relationship between damage assessment information and a third-party platform are pre-set in the system of the health insurance claims platform. After the health insurance claims platform determines the insurance liability corresponding to the cause of the insurance accident, a damage assessment information list is generated based on the mapping relationship between insurance liability and damage assessment information and the insurance liability corresponding to the above-mentioned first semantic recognition result in the above-mentioned policy information; then, based on the mapping relationship between the damage assessment information and the third-party platform and the above-mentioned damage assessment information list, the above-mentioned acquisition request for obtaining damage assessment information from the third-party platform for the above-mentioned insurance accident is generated. Among them, the above-mentioned acquisition request includes an information list of the damage assessment information to be obtained and the identity information of the insured.

[0109] 206: Send the above acquisition request to the above third-party platform, wherein the above acquisition request includes a list of damage information.

[0110] 207: receiving the damage information fed back by the third-party platform in response to the damage information acquisition request, the damage information sent by the third-party platform is information obtained by the third-party platform from the third-party platform database according to the damage information list.

[0111] 208: Conduct loss assessment for the above insurance accident based on the loss assessment information sent by the above third-party platform and the above insurance policy information.

[0112] In an embodiment of the present application, after the above-mentioned health insurance claims platform obtains the above-mentioned health insurance loss information, the health insurance claims platform pre-processes the above-mentioned loss information (for example, semantic recognition of text information, image recognition of images, and then structured processing of the loss information) to obtain loss data that the system can recognize, and then the health insurance claims platform obtains the loss rules from the rule library based on the mapping relationship between insurance liability and loss rules and the insurance liability corresponding to the above-mentioned first semantic recognition result in the above-mentioned policy information; wherein, the above-mentioned loss rules include medical expense calculation rules and third-party expense calculation rules, and the above-mentioned medical expense calculation rules include at least one of hospitalization expense calculation rules, outpatient emergency expense calculation rules, and outpatient surgery expense calculation rules. Next, the above-mentioned health insurance claims platform calculates the medical expenses and third-party expenses of the above-mentioned insured person based on the above-mentioned loss data and the above-mentioned loss rules; wherein, the above-mentioned medical expenses include at least one of hospitalization expenses, outpatient emergency expenses, and outpatient surgery expenses. Finally, the health insurance claims platform calculates the claim amount that the insurer needs to pay in the above insurance accident based on the above insured's medical expenses, the above insured's third-party expenses, and the deductible information and compensation ratio information contained in the above policy information.

[0113] Among them, the above-mentioned health insurance claims platform calculates the claim amount that the insurer needs to pay in the above-mentioned insurance accident based on the medical expenses of the above-mentioned insured, the third-party expenses of the above-mentioned insured, and the deductible information and compensation ratio information contained in the above-mentioned policy information. Specifically, it may include: the health insurance claims platform calculates the deductible expenses in the above-mentioned medical expenses based on the deductible information contained in the above-mentioned policy information, and then deducts the above-mentioned deductible expenses and the above-mentioned third-party expenses from the above-mentioned medical expenses and multiplies the final expenses by the compensation ratio in the above-mentioned compensation ratio information to determine the above-mentioned claim amount.

[0114] 209: Generate a claim expense list based on the loss assessment result of the insurance accident, generate feedback information based on the claim expense list, and send the feedback information to the user terminal.

[0115] In an embodiment of the present application, after the health insurance claims platform calculates the claim amount based on the loss assessment information and the policy information, the health insurance claims platform generates a claim expense list based on the loss assessment results of the above-mentioned insurance accident, and generates feedback information based on the above-mentioned claim expense list; then the above-mentioned feedback information is sent to the user terminal so that the user can clearly understand the claim result.

[0116] It can be seen that the embodiment of the present application receives the health insurance claim request sent by the applicant through the health insurance claim platform, and then obtains the policy information of the health insurance type insured by the insured from the database, and determines the loss assessment information required for the above-mentioned insurance accident based on the above-mentioned health insurance claim request and policy information, as well as the third-party platform for obtaining this information. Then the health insurance claim platform initiates a request to obtain the loss assessment information to the third-party platform, and receives the loss assessment information sent by the third-party platform. Finally, the health insurance claim platform performs loss assessment on the above-mentioned insurance accident based on the loss assessment information sent by the above-mentioned third-party platform and the above-mentioned policy information, and generates feedback information based on the result of the loss assessment, and sends the feedback information to the user terminal. Through the embodiment of the present application, the work efficiency of health insurance claims and loss assessment can be effectively improved, labor costs can be saved, loss assessment standards can be unified, and deviations caused by human subjective factors in the loss assessment process can be avoided.

[0117] The embodiment of the present application also provides a server, which is used to execute any of the above methods. Figure 3 , Figure 3 The server of this embodiment includes: a receiving unit 310 , a first obtaining unit 320 , a generating unit 330 , a sending unit 340 and a claim settlement unit 350 .

[0118] The receiving unit 310 is used to receive a health insurance claim request for an insurance accident from a user terminal;

[0119] The first acquisition unit 320 is used to respond to the health insurance claim request and acquire the policy information of the health insurance type insured by the insured from the database according to the insured identity information included in the health insurance claim request;

[0120] The generating unit 330 is used to generate a request for obtaining damage information including a damage information list according to the insurance policy information and the claim information included in the health insurance claim request;

[0121] The sending unit 340 is used to send the acquisition request to the third-party platform;

[0122] The receiving unit 310 is further configured to receive the damage information fed back by the third-party platform in response to the damage information acquisition request, wherein the damage information sent by the third-party platform is information obtained by the third-party platform from a database of the third-party platform according to the damage information list and the identity information of the insured;

[0123] The claim settlement unit 350 is used to carry out loss assessment processing on the above-mentioned insurance accident based on the loss assessment information sent by the above-mentioned third-party platform and the above-mentioned policy information.

[0124] Optionally, the above-mentioned claim settlement information also includes the time of occurrence of the insurance accident;

[0125] The above server also includes:

[0126] The first judgment unit 360 is used to judge whether the time of occurrence of the insurance accident is within the insurance period included in the insurance policy information; if the time of occurrence of the insurance accident is within the insurance period included in the insurance policy information, then judge whether the time of occurrence of the insurance accident is after the waiting period included in the insurance policy information;

[0127] The generation unit 330 is used to execute the step of generating a request for obtaining damage assessment information from a third-party platform for the insurance accident based on the insurance policy information and the claim information included in the health insurance claim request if the insurance accident occurs after the waiting period included in the policy information.

[0128] Optionally, the above-mentioned claim settlement information includes the cause of the insurance accident;

[0129] The above generation unit includes:

[0130] The first recognition unit 331 is used to perform semantic recognition on the cause of the insurance accident to obtain a first semantic recognition result;

[0131] The second judgment unit 332 is used to judge the insurance liability corresponding to the first semantic recognition result in the insurance policy information according to the first semantic recognition result;

[0132] The above-mentioned generation unit 330 is also used to generate a damage information list based on the mapping relationship between insurance liability and damage information and the insurance liability in the above-mentioned policy information corresponding to the above-mentioned first semantic recognition result; based on the mapping relationship between the damage information and the third-party platform and the above-mentioned damage information list, generate the above-mentioned acquisition request for obtaining the damage information from the third-party platform for the above-mentioned insurance accident, and the above-mentioned acquisition request includes the damage information list.

[0133] Optionally, the server further includes:

[0134] The second recognition unit 370 is used to perform semantic recognition on the text information in the damage information sent by the third-party platform to obtain a second semantic recognition result, and perform image recognition on the image information in the damage information sent by the third-party platform to obtain an image recognition result;

[0135] The processing unit 380 is used to structure the second semantic recognition result, the image recognition result and other information in the damage information sent by the third-party platform except text information and image information according to a preset structured format to obtain damage data.

[0136] Optionally, the claim settlement unit 350 includes:

[0137] The second acquisition unit 351 is used to acquire the loss assessment rule from the rule library according to the mapping relationship between the insurance liability and the loss assessment rule and the insurance liability corresponding to the first semantic recognition result in the above-mentioned policy information, wherein the above-mentioned loss assessment rule includes a medical expense calculation rule and a third-party expense calculation rule, and the above-mentioned medical expense calculation rule includes at least one of a hospitalization expense calculation rule, an outpatient emergency expense calculation rule, and an outpatient surgery expense calculation rule;

[0138] A calculation unit 352 is used to calculate the medical expenses and third-party expenses of the insured according to the loss assessment data and the loss assessment rules, wherein the medical expenses include at least one of hospitalization expenses, outpatient emergency expenses, and outpatient surgery expenses;

[0139] The calculation unit 352 is also used to calculate the claim amount that the insurer needs to pay in the insurance accident based on the medical expenses of the insured, the third-party expenses of the insured, and the deductible information and compensation ratio information contained in the policy information.

[0140] Optionally, the calculation unit 352 is used to calculate the deductible in the medical expenses according to the deductible information contained in the policy information; the final cost obtained by deducting the deductible and the third-party costs from the medical expenses and multiplying the cost by the compensation ratio in the compensation ratio information is determined as the claim amount.

[0141] Optionally, the server further includes:

[0142] Feedback unit 390, used to generate a claim expense list according to the result of loss assessment of the insurance accident, and generate feedback information according to the claim expense list;

[0143] The sending unit 340 is used to send the feedback information to the user terminal.

[0144] It can be seen that the embodiment of the present application receives the health insurance claim request sent by the applicant through the health insurance claim platform, and then obtains the policy information of the health insurance type insured by the insured from the database, and determines the loss assessment information required for the above-mentioned insurance accident based on the above-mentioned health insurance claim request and policy information, as well as the third-party platform for obtaining this information. Then the health insurance claim platform initiates a request to obtain the loss assessment information to the third-party platform, and receives the loss assessment information sent by the third-party platform. Finally, the health insurance claim platform performs loss assessment on the above-mentioned insurance accident based on the loss assessment information sent by the above-mentioned third-party platform and the above-mentioned policy information, and generates feedback information based on the result of the loss assessment, and sends the feedback information to the user terminal. Through the embodiment of the present application, the work efficiency of health insurance claims and loss assessment can be effectively improved, labor costs can be saved, loss assessment standards can be unified, and deviations caused by human subjective factors in the loss assessment process can be avoided.

[0145] See also Figure 4 , Figure 4 is a device provided in an embodiment of the present application, which may be a server, such as Figure 4 The device shown includes: one or more processors 401; one or more input devices 402, one or more output devices 403 and a memory 404. The processor 401, input device 402, output device 403 and memory 404 are connected via a bus 405. The memory 404 is used to store instructions, and the processor 401 is used to execute the instructions stored in the memory 404.

[0146] In which, when the device is used as a server, the processor 401 is used to: receive a health insurance claim request for an insurance accident from a user terminal, respond to the above health insurance claim request, and obtain the policy information of the health insurance type insured by the insured from the database according to the insured identity information included in the above health insurance claim request; generate damage information including a damage information list based on the above policy information and the claim information included in the above health insurance claim request, and send the above acquisition request to the above third-party platform; receive the damage information sent by the above third-party platform, the damage information fed back by the above third-party platform in response to the damage information acquisition request is the information obtained by the above third-party platform from the third-party platform database according to the above damage information list; and perform damage processing on the above insurance accident based on the damage information sent by the above third-party platform and the above policy information.

[0147] It should be understood that in the embodiment of the present application, the processor 401 may be a central processing unit (CPU), and the processor may also be other general-purpose processors, digital signal processors (DSP), application-specific integrated circuits (ASIC), field-programmable gate arrays (FPGA) or other programmable logic devices, discrete gate or transistor logic devices, discrete hardware components, etc. A general-purpose processor may be a microprocessor or the processor may also be any conventional processor, etc.

[0148] The input device 402 may include a touch panel, a fingerprint sensor (for collecting fingerprint information of the user and fingerprint direction information), a microphone, etc. The output device 403 may include a display (LCD, etc.), a speaker, etc.

[0149] The memory 404 may include a read-only memory and a random access memory, and provide instructions and data to the processor 401. A portion of the memory 404 may also include a non-volatile random access memory. For example, the memory 404 may also store information about the device type.

[0150] In a specific implementation, the processor 401, input device 402, and output device 403 described in the embodiments of the present application can execute the implementation method described in the first embodiment, the second embodiment, and the third embodiment of a health insurance loss assessment data processing method provided in the embodiments of the present application, and can also execute the implementation method of the server described in the embodiments of the present application, which will not be repeated here.

[0151] In another embodiment of the present application, a computer-readable storage medium is provided, and the computer-readable storage medium stores a computer program, which, when executed by a processor, implements: receiving a health insurance claim request for an insurance accident from a user terminal, responding to the health insurance claim request, and obtaining policy information of the health insurance type insured by the insured from a database according to the insured's identity information included in the health insurance claim request; generating damage information including a damage information list according to the policy information and the claim information included in the health insurance claim request, and sending the acquisition request to the third-party platform; receiving damage information fed back by the third-party platform in response to the damage information acquisition request, the damage information sent by the third-party platform being information obtained by the third-party platform from the third-party platform database according to the damage information list; and performing damage processing on the insurance accident according to the damage information sent by the third-party platform and the policy information.

[0152] The computer-readable storage medium may be an internal storage unit of the terminal in any of the aforementioned embodiments, such as a hard disk or memory of the terminal. The computer-readable storage medium may also be an external storage device of the terminal, such as a plug-in hard disk, a smart memory card (Smart Media Card, SMC), a secure digital (SecureDigital, SD) card, a flash card (Flash Card), etc. equipped on the terminal. Further, the computer-readable storage medium may also include both an internal storage unit of the terminal and an external storage device. The computer-readable storage medium is used to store the computer program and other programs and data required by the terminal. The computer-readable storage medium may also be used to temporarily store data that has been output or is to be output.

[0153] Figure 5 : is a schematic diagram of a server structure provided in an embodiment of the present application. The server 500 may have relatively large differences due to different configurations or performances, and may include one or more central processing units (CPU) 522 (for example, one or more processors) and a memory 532, and one or more storage media 530 (for example, one or more mass storage devices) storing application programs 542 or data 544. Among them, the memory 532 and the storage medium 530 can be short-term storage or permanent storage. The program stored in the storage medium 530 may include one or more modules (not shown in the figure), and each module may include a series of instruction operations in the server. Furthermore, the central processing unit 522 can be configured to communicate with the storage medium 530 to execute a series of instruction operations in the storage medium 530 on the server 500.

[0154] The server 500 may also include one or more power supplies 526, one or more wired or wireless network interfaces 550, one or more input and output interfaces 558, and / or one or more operating systems 541, such as Windows ServerTM, Mac OS XTM, UnixTM, LinuxTM, FreeBSDTM, etc.

[0155] The steps performed by the server in the above embodiment can be based on the Figure 5 The server structure shown.

[0156] Those of ordinary skill in the art will appreciate that the units and algorithm steps of each example described in conjunction with the embodiments disclosed herein can be implemented in electronic hardware, computer software, or a combination of the two. In order to clearly illustrate the interchangeability of hardware and software, the composition and steps of each example have been generally described in terms of function in the above description. Whether these functions are performed in hardware or software depends on the specific application and design constraints of the technical solution. Professional and technical personnel can use different methods to implement the described functions for each specific application, but such implementation should not be considered to be beyond the scope of this application.

[0157] Those skilled in the art can clearly understand that, for the convenience and brevity of description, the specific working processes of the above-described systems, servers, terminal devices and units can refer to the corresponding processes in the aforementioned method embodiments and will not be repeated here.

[0158] In the several embodiments provided in the present application, it should be understood that the disclosed systems, servers and methods can be implemented in other ways. For example, the device embodiments described above are merely schematic. For example, the division of the above units is only a logical function division. There may be other division methods in actual implementation, such as multiple units or components can be combined or integrated into another system, or some features can be ignored or not executed. In addition, the mutual coupling or direct coupling or communication connection shown or discussed can be an indirect coupling or communication connection through some interfaces, devices or units, or it can be an electrical, mechanical or other form of connection.

[0159] The units described above as separate components may or may not be physically separated, and the components shown as units may or may not be physical units, that is, they may be located in one place or distributed on multiple network units. Some or all of the units may be selected according to actual needs to achieve the purpose of the embodiments of the present application.

[0160] In addition, each functional unit in each embodiment of the present application may be integrated into one processing unit, or each unit may exist physically separately, or two or more units may be integrated into one unit. The above-mentioned integrated unit may be implemented in the form of hardware or in the form of software functional units.

[0161] If the above-mentioned integrated unit is implemented in the form of a software functional unit and sold or used as an independent product, it can be stored in a computer-readable storage medium. Based on this understanding, the technical solution of the present application is essentially or the part that contributes to the prior art, or all or part of the technical solution can be embodied in the form of a software product, and the computer software product is stored in a storage medium, including a number of instructions to enable a computer device (which can be a personal computer, server, or network device, etc.) to perform all or part of the steps of the above-mentioned methods in each embodiment of the present application. The aforementioned storage medium includes: U disk, mobile hard disk, read-only memory (ROM, Read-Only Memory), random access memory (RAM, Random Access Memory), disk or optical disk and other media that can store program code.

[0162] The above is only a specific implementation of the present application, but the protection scope of the present application is not limited thereto. Any technician familiar with the technical field can easily think of various equivalent modifications or replacements within the technical scope disclosed in the present application, and these modifications or replacements should be included in the protection scope of the present application. Therefore, the protection scope of the present application shall be based on the protection scope of the claims.

Claims

1. A method for processing health insurance loss assessment data, characterized in that: include: Receiving a health insurance claim request for an insurance accident from a user terminal, and acquiring policy information of the health insurance type purchased by the insured from a database according to the identity information of the insured included in the health insurance claim request; Generate a request for obtaining damage information including a list of damage information based on the insurance policy information and the claim information included in the health insurance claim request, and send the request to a third-party platform; The third-party platform is a third-party platform corresponding to the damage information in the damage information list; the acquisition request is sent to one or more third-party platforms; the claim information includes the cause of the insurance accident; The generating of a request for obtaining damage information including a list of damage information based on the policy information and the claim information included in the health insurance claim request includes: performing semantic recognition on the cause of the insurance accident to obtain a first semantic recognition result; judging the insurance liability corresponding to the first semantic recognition result in the policy information based on the first semantic recognition result; generating a list of damage information based on a mapping relationship between insurance liability and damage information and the insurance liability corresponding to the first semantic recognition result in the policy information; generating a request for obtaining damage information from a third-party platform for the insurance accident based on a mapping relationship between damage information and a third-party platform and the damage information list; Receiving the damage information fed back by the third-party platform in response to the damage information acquisition request, wherein the damage information is information acquired by the third-party platform from a third-party platform database according to the damage information list; Obtaining loss assessment rules from a rule base according to a mapping relationship between insurance liability and loss assessment rules and the insurance liability corresponding to the first semantic recognition result in the policy information, wherein the loss assessment rules include medical expense calculation rules and third-party expense calculation rules, and the medical expense calculation rules include at least one of hospitalization expense calculation rules, outpatient emergency expense calculation rules, and outpatient surgery expense calculation rules; Calculate the medical expenses and third-party expenses of the insured person according to the loss assessment data and the loss assessment rules, wherein the medical expenses include at least one of hospitalization expenses, outpatient emergency expenses, and outpatient surgery expenses; The claim amount that the insurer needs to pay in the insurance accident is calculated based on the insured's medical expenses, the insured's third-party expenses, and the deductible information and compensation ratio information contained in the policy information.

2. The method according to claim 1, characterized in that The claim settlement information also includes the time of occurrence of the insurance accident; After acquiring the policy information of the health insurance type purchased by the insured from the database according to the insured's identity information included in the health insurance claim request, the method further includes: Determining whether the time of occurrence of the insurance accident is within the insurance period included in the insurance policy information; If the time when the insurance accident occurs is within the insurance period included in the policy information, then determining whether the time when the insurance accident occurs is after the waiting period included in the policy information; If the time when the insurance accident occurs is after the waiting period included in the policy information, the step of generating a request for obtaining damage assessment information from a third-party platform for the insurance accident based on the policy information and the claim information included in the health insurance claim request is executed.

3. The method according to claim 1, characterized in that After receiving the damage assessment information sent by the third-party platform, and before performing damage assessment processing on the insurance accident according to the damage assessment information sent by the third-party platform and the insurance policy information, the method further includes: Performing semantic recognition on text information in the damage information sent by the third-party platform to obtain a second semantic recognition result, and performing image recognition on image information in the damage information sent by the third-party platform to obtain an image recognition result; The second semantic recognition result, the image recognition result, and other information in the damage information sent by the third-party platform except text information and image information are structured according to a preset structured format to obtain damage data.

4. The method according to claim 1, characterized in that: The calculation of the claim amount that the insurer needs to pay in the insurance accident based on the medical expenses of the insured, the third-party expenses of the insured, and the deductible information and compensation ratio information contained in the policy information includes: Calculating the deductible amount of the medical expenses according to the deductible amount information included in the insurance policy information; The final cost obtained by deducting the deductible and the third-party costs from the medical expenses and multiplying it by the compensation ratio in the compensation ratio information is determined as the claim amount.

5. The method according to any one of claims 1 to 4, characterized in that: After performing loss assessment on the insurance accident according to the loss assessment information sent by the third-party platform and the insurance policy information, the method further includes: generating a claim expense list based on the loss assessment result of the insurance accident, and generating feedback information based on the claim expense list; Sending the feedback information to the user terminal.

6. A server, characterized in that: The method comprises means for executing the method according to any one of claims 1 to 5.

7. A server, characterized in that: The server includes a processor, a memory and a communication module, wherein the memory is used to store program codes, and the processor is used to call the program codes to execute the method according to any one of claims 1 to 5.

8. A computer-readable storage medium, characterized in that: The computer-readable storage medium stores a computer program, wherein the computer program includes program instructions, and when the program instructions are executed by a processor, the processor is caused to perform the method according to any one of claims 1 to 5.

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