Intelligent claim settlement application method and system based on claim settlement service management

Abstract

The invention discloses an intelligent claim settlement application method and system based on claim settlement service management, and relates to the technical field of intelligent claim settlement application. In order to solve the problems that customer claim settlement procedures are tedious, material uploading is inconvenient, and a large amount of time and energy are consumed; the problems that the claim settlement accepting and auditing efficiency is low, the period is long, the cost is high, data are often inconsistent with contracts, and consequently the claim settlement fails or the claim is insufficient, and the claim payment rate is difficult to control are solved; the method can generate the data chain according to the claim settlement data submitted by the insured, directly judges the claim settlement application and determines the claim settlement application item based on the matching of the insurance policy information, and quickly creates the claim settlement application form or associates the claim settlement data to the claim settlement application form based on the processing suggestion of the claim settlement application. According to the actual accident of the insured person and the occurrence of the corresponding cost, the matching of the claim settlement application item and the corresponding insurance policy is intelligently carried out, the service process of the insurance intermediary service personnel for the insurance claim settlement application of the insured person is simplified, and the service efficiency is improved.

Description

Technical Field

[0001] The present invention relates to the technical field of intelligent claim application, and particularly to an intelligent claim application method and system based on claim service management. Background Art

[0002] Currently, the claim management carried out by insurance intermediaries basically follows the process of insurance companies, asking users to provide claim application forms, and simply recording the corresponding policy numbers and claim materials in tabular form for claim management.

[0003] However, in traditional claim management systems, customers often have to face complex and cumbersome claim procedures, manually input a large amount of information, the process is extremely cumbersome, and the material upload link is not convenient enough, resulting in customers spending a lot of time and energy in handling claim business, seriously weakening the ability of insurance intermediaries to serve customers and reducing customer satisfaction.

[0004] Moreover, in key processes such as claim acceptance and material review, not only is the efficiency low, the claim cycle is long, but also a large amount of human and material resources are consumed, resulting in situations where the occurrence time shown in the claim materials does not match the insurance contract, and the claim items do not actually match the expense items shown in the claim materials, ultimately leading to the failure of claim applications or underpayment, and being unable to effectively guarantee the claim quality, resulting in difficulties in controlling the loss ratio. Summary of the Invention

[0005] The purpose of the present invention is to provide an intelligent claim application method and system based on claim service management, which realizes the intelligent processing of claim materials, the automatic generation and association of claim applications, simplifies the claim process, improves the claim efficiency and accuracy, and provides efficient and convenient claim service management for insurance intermediaries to solve the problems raised in the above background art.

[0006] To achieve the above purpose, the present invention provides the following technical solutions:

[0007] An intelligent claim application method based on claim service management, comprising:

[0008] Obtaining the identity information of the user and uploading the materials related to the claim application, establishing a claim material file list through the claim materials uploaded by the user to the cloud, classifying the claim materials and identifying the corresponding key information;

[0009] Based on the recognition result, obtaining personal protection information and the corresponding policy information according to the association system, and generating a personal protection information list;

[0010] According to each claim material identified in the claim material file list, constructing the association relationship between the materials to form a data chain;

[0011] Judge the claim items according to the data chain, match the personal protection information according to the claim items and the corresponding data chain, and judge whether to generate a claim form or associate a claim form according to the time matching and insurance type matching rules;

[0012] Generate a claim form under the condition of meeting the requirements according to the judgment result, automatically generate a claim application form, and associate the corresponding claim materials.

[0013] Furthermore, obtain the user's identity information and upload the materials related to the claim application, specifically including:

[0014] The user uploads the personal identity information and claim-related materials to the cloud;

[0015] Extract the name of the insured from the claim-related materials uploaded by the user, use the name of the insured as the file storage name established in the cloud, randomly generate a unique identifier for the file storage, and at the same time associate and store information such as the name of the insured, ID number, data upload platform, number of data sheets, creator, and creation time in the cloud to form a claim material file list;

[0016] In the claim material file list, present the claim material information submitted each time in the form of a separate record, and obtain all the file material records submitted by the user for the insured through the claim file list.

[0017] Furthermore, classify the claim materials and identify the corresponding key information, specifically including:

[0018] Preprocess the claim material images uploaded by the user, input the preprocessed claim material images into a pre-trained classification model, classify according to the characteristics of the claim material images, and determine the type of the claim material images;

[0019] Determine the key information areas of each type of claim material, segment the claim material images into multiple regions based on image segmentation technology, and match the segmented regions with the key information areas to determine the type of key information corresponding to each region;

[0020] Based on the matching result, convert the text in each region into text information, determine it as the key information of the claim materials uploaded by the user, and determine the corresponding type of key information.

[0021] Furthermore, generate a personal protection information list, specifically including:

[0022] Based on the file record format in the claim material file list, locate the fields of the name of the insured, ID type, and ID number stored in each claim material file, and integrate and generate a basic data set for querying personal protection information;

[0023] Establish a connection channel with the associated system for storing personal guarantee information, send the basic dataset to the associated system, and create a storage space for the corresponding personal guarantee information in the associated system using the insured's name in the basic dataset as the index;

[0024] Generate separate records based on the ID number field, associate the personal guarantee information with the insured's name, and for multiple personal guarantee information items under each insured, record them in list form respectively, and sort the personal guarantee information according to the guarantee effective date and guarantee expiration date.

[0025] Furthermore, construct the association relationships between the materials to form a data chain, specifically including:

[0026] Traverse the list of claim settlement material files, and for each completely identified claim settlement file record, extract the claim settlement materials in the claim settlement file record according to the preset material classification rules;

[0027] Obtain the association information required by the association rules from the extracted claim settlement materials, and perform association matching between the claim settlement materials according to the association rules and the extracted association information;

[0028] Based on the matching results, verify the association relationships between the claim settlement materials, judge the effective associations between the claim settlement materials, and integrate the verified material association relationships to generate the corresponding material association matching data chain under a single claim settlement file record.

[0029] Furthermore, judge the claim settlement items, specifically including:

[0030] Read the preset claim settlement item material matching rules from the claim settlement form database, and determine the judgment criteria and required materials for each claim settlement item based on the claim settlement item category;

[0031] Apply the trained claim settlement item material matching model to the actual claim settlement application, traverse each claim settlement material in the data chain, and for each claim settlement item, check the integrity of the required materials for this item in the data chain to screen out the set of eligible claim settlement items;

[0032] Judge whether there are special circumstances in the set of claim settlement items, sort out the set of possible application items after special circumstance judgment and processing, remove duplicate or ineligible items, and record the claim settlement material list corresponding to each item at the same time.

[0033] Furthermore, judge whether to generate a claim settlement form or associated claim settlement, specifically including:

[0034] Extract the medical treatment time information related to the claim settlement items in the claim settlement item set from the data chain, and compare it with the guarantee effective date and guarantee expiration date in the personal guarantee information;

[0035] If the consultation time is within the guarantee period, it is determined that the time match is successful, and the subsequent insurance type matching is continued; if the consultation time is not within the guarantee period, it is directly determined that the claim settlement conditions are not met, the insurance type matching is no longer carried out, and the reason for the time mismatch is recorded;

[0036] Obtain the policy insurance type in the personal guarantee information and compare it with the insurance type required by the claim settlement item;

[0037] If the insurance type matches, continue to the next judgment; if the insurance type does not match, it is determined that the claim settlement conditions are not met, the reason for the insurance type mismatch is recorded, and the subsequent judgment process is stopped;

[0038] Query in the claim settlement form database according to the policy number corresponding to the claim settlement item and the extracted consultation time. If a claim settlement form record with the same consultation time and policy number is found, it is determined that the claim settlement materials and the corresponding data group are associated with the corresponding claim settlement form, and the association information is recorded; if no relevant record is found, a new claim settlement form is generated

[0039] Furthermore, automatically generating a claim settlement application form further includes: for the materials and data chains that meet the conditions for associating with the claim settlement form, displaying the corresponding claim settlement application form information in terms of the matching policy number. After the user operates, the association operation is completed, realizing the association between the claim settlement materials and the existing claim settlement application form.

[0040] The present invention provides another technical solution, an intelligent claim settlement application system based on claim settlement service management, including:

[0041] A user information acquisition module, configured to determine the claim settlement material file list of the insured based on the materials uploaded by the user, and extract the corresponding claim settlement materials and corresponding key information based on the accident information of the insured;

[0042] A relevance calculation module, configured to construct data associations between claim settlement materials according to association rules, match the accident information of the insured with the policy information, and determine whether to generate a new claim settlement form or associate with an existing claim settlement form based on the matching result;

[0043] An associated claim settlement recommendation module, configured to recommend a new claim settlement form and an associated claim settlement form to the user and guide the user to complete the claim settlement application operation when the judgment result meets the conditions for generating a claim settlement form.

[0044] Furthermore, the relevance calculation module further includes: quantitatively evaluating the matching degree of the accident information of the insured with the policy information, calculating the association value between the corresponding claim settlement materials and the policy information based on the evaluation result. At the same time, for multiple claim settlement items or policies, sorting them according to the size of the association value and preferentially processing the claim settlement applications with high association values.

[0045] Compared with the prior art, the beneficial effects of the present invention are as follows:

[0046] It can, according to the claim settlement materials submitted by the insured, generate a match based on the policy information according to the systematic data chain, directly judge the claim settlement application and determine the claim settlement application items, and quickly create a claim settlement application form or associate it with the claim settlement application form based on the processing suggestions of the claim settlement application. Thus, according to the actual accident of the insured and the occurrence of corresponding expenses, it can intelligently match the claim settlement application items and the corresponding policies. Furthermore, it simplifies the service process of the insurance intermediary service personnel for the insured's insurance claim settlement application and improves the service efficiency; at the same time, in terms of the service quality for the insured, it provides more accurate and effective claim settlement services through a systematic method. BRIEF DESCRIPTION OF THE DRAWINGS

[0047] Figure 1 It is a flowchart of the intelligent claim settlement application method based on claim settlement service management of the present invention;

[0048] Figure 2 It is a module diagram of the intelligent claim settlement application system based on claim settlement service management of the present invention. DETAILED DESCRIPTION OF THE EMBODIMENTS

[0049] Next, the technical solutions in the embodiments of the present invention will be clearly and completely described in conjunction with the accompanying drawings in the embodiments of the present invention. Obviously, the described embodiments are only a part of the embodiments of the present invention, rather than all the embodiments. All other embodiments obtained by those of ordinary skill in the art based on the embodiments of the present invention without creative efforts shall fall within the protection scope of the present invention.

[0050] In order to solve the technical problems of cumbersome claim settlement procedures for customers, inconvenient material uploading, consuming a large amount of time and energy, reducing satisfaction; low efficiency, long cycle, high cost in claim settlement acceptance and review, and often situations where the materials do not match the contract, resulting in claim settlement failure or underpayment, and difficulty in controlling the loss ratio, please refer to Figure 1 This embodiment provides the following technical solutions:

[0051] An intelligent claim settlement application method based on claim settlement service management, including:

[0052] Obtain the identity information of the user and upload the materials related to the claim settlement application, establish a claim settlement material file list through the claim settlement materials uploaded by the user to the cloud, including information such as user information, number of materials, creator, creation time, etc., classify the claim settlement materials and identify the corresponding key information;

[0053] Based on the recognition result, obtain the personal guarantee information and the corresponding policy information according to the associated system, and generate a personal guarantee information list;

[0054] For each claim data identified in the claim data file list, establish the association relationships between the data. For example, associate the outpatient invoice with the outpatient medical record based on the visit date, and associate the inpatient invoice with the discharge summary and expense list based on the inpatient number to form a data chain;

[0055] And determine the claim items based on the data chain, such as outpatient medical treatment, inpatient medical treatment, inpatient allowance, etc. According to the claim items and the corresponding data chain, match the personal protection information, and judge whether to generate a claim form or associate a claim form according to the time matching and insurance type matching rules. Specifically, it includes:

[0056] Based on the claim data file of the insured and the claim data information that has been identified and obtained, establish the data chain for the associated matching of the corresponding data under a single claim file; establish a claim item data matching model, and judge the claim item according to the data chain generated by the claim file; according to the claim item and the corresponding data chain, match the personal protection information, and form a judgment on whether to generate a claim form or associate a claim form according to the time matching and insurance type matching rules;

[0057] Generate a claim form under the condition of meeting the requirements according to the judgment result. According to the matched policy information, the earliest visit time of the claim data, the visit medical institution and other information, automatically generate a claim application form and associate the corresponding claim data. It also includes: for the data and data chain that meet the conditions for associating a claim form, display the corresponding claim application form information in terms of the matched policy number, provide a "Associate Claim Form" button, and after the user operates, complete the association operation to realize the association between the claim data and the existing claim application form.

[0058] In this embodiment, for the data and the corresponding data chain that meet the conditions for generating a claim form, generate the corresponding claim form generation suggestion record in terms of the matched policy number. The displayed content includes the policy start time, policy end time, customer name, policy number, insured's name, and insured's ID number. The corresponding operation button is displayed as "New Claim Form". When operating the "New Claim Form", the system will automatically generate a claim application form, retrieve the policy information, the earliest visit time of the claim data as the accident occurrence time, and the visit medical institution as the accident occurrence location, and automatically associate the currently existing claim data according to the determination of the claim application item and the matching of the corresponding data chain of the claim data. The insured's name and ID information are correspondingly filled in the fields of the claim application form. After the user operates and submits, complete the operation of generating the claim application form. For the data and the corresponding data chain that meet the conditions for associating a claim form, display the corresponding claim form in terms of the matched policy number. The displayed content includes the case number, report number, status, policy start time, policy end time, customer name, policy number, insured's name, and insured's ID number. Provide a "Associate Claim Form" button in the operation column for the association operation.

[0059] In this embodiment, by automatically identifying and classifying claim settlement materials, constructing a data chain, and based on association rules and claim settlement item models, intelligent judgment of claim settlement applications and item matching are realized, effectively simplifying the claim settlement process, improving the efficiency and accuracy of claim settlement. According to the actual accidents and expense occurrences of the insured, the corresponding claim settlement items and insurance policies are intelligently matched, avoiding problems such as inconsistent materials and mismatched items that occur in the traditional claim settlement process, significantly improving the quality of claim settlement services, and also being able to reduce the workload of insurance intermediary service personnel, lower operating costs, and ultimately realize the automation and intelligence of the claim settlement process, bringing greater development space for the insurance industry.

[0060] In this embodiment, obtaining the identity information of the user and uploading the materials related to the relevant claim settlement application specifically includes:

[0061] The user uploads personal identity information (name, document type, document number, etc.) and claim settlement related materials (medical records, invoices, expense lists, etc.) to the cloud through the personal user terminal or by entrusting an intermediary service personnel;

[0062] Extract the name of the insured from the claim settlement related materials uploaded by the user, use the name of the insured as the name for archiving the materials established in the cloud, randomly generate a unique identifier (file number) for archiving the materials, and at the same time associate and store information such as the name of the insured, document number, material upload platform, number of material sheets, creator, and creation time in the cloud to form a claim settlement materials archive list;

[0063] In the claim settlement materials archive list, the information of each submitted claim settlement material is presented in the form of a separate record. All the archive material records submitted by the user for the insured are obtained through the claim settlement archive list and used as the information collection basis for the intelligent claim settlement application;

[0064] For example, (file number, name, document number, source, number of material sheets, creator, creation date). The claim settlement materials archive list is the name of all insureds who have submitted claim settlement materials. Different users or the same user will generate a separate claim settlement materials archive record according to the claim settlement materials of the insured when submitting new ones. For example, (file number, Zhang San, 11223344556677889, system scan, 20 sheets, 2024-11-5 15:00:30,.......″) indicates that the file number is for the insured with the name Zhang San by the user (creator), the document number is 11223344556677889, and 20 claim settlement application materials were submitted through system scan at 15:00:30 on November 5, 2024;

[0065] In this embodiment, classifying the claim settlement materials and identifying the corresponding key information specifically includes:

[0066] Preprocess the images of claim settlement materials uploaded by users, including operations such as image denoising, size adjustment, and contrast enhancement, to improve the image quality and enhance the recognition accuracy of the classification model; input the preprocessed images of claim settlement materials into a pre-trained classification model, classify according to the characteristics of the images of claim settlement materials, and determine the type of the images of claim settlement materials, such as "identity document", "bank card", etc. The classification model is constructed by training a deep learning-based image classification model with a large number of data samples and can identify and distinguish different types of claim settlement materials, such as identity documents, bank cards, medical records, invoices, etc.

[0067] Determine the key information areas of each type of claim settlement materials, such as the name and ID number areas on the identity document, the invoice number and amount areas on the invoice, etc. Based on image segmentation technology, segment the images of claim settlement materials into multiple areas, such as segmenting the identity document into a head portrait area, a text information area, etc., and match the segmented areas with the key information areas to determine the type of key information corresponding to each area.

[0068] Based on the matching results, convert the text in each area into text information, such as identifying the name and ID number on the identity document as the corresponding text strings, determine them as the key information of the claim settlement materials uploaded by this user, and determine the corresponding key information types.

[0069] In this embodiment, to accurately create a claim settlement application for the claim settlement materials submitted by users and improve work efficiency, the uploaded materials will be classified first. Overall, it will be divided into identity documents, bank cards, medical records, invoices, expense lists, discharge summaries, admission summaries, claim settlement application forms, and other materials. Through the classification of the materials, standardize the information of the materials that need to be collected for the corresponding materials. For example: the information that needs to be collected for the ID card includes name, ID number, address, expiration date; the information that needs to be collected for the invoice includes name, invoice number, invoice date, whether it is an electronic invoice, date of medical treatment, whether it is a medical insurance visit, total cost, personal out-of-pocket expenses, name of medical institution, type of medical institution, whether it is a split bill, social security co-ordination, other co-ordination / assistance / grant.

[0070] In this embodiment, generate a personal guarantee information list, which specifically includes:

[0071] Based on the file record format in the claim settlement materials file list, locate the fields of the insured's name, document type, and document number stored in each claim settlement materials file, and integrate and generate a basic data set for querying personal guarantee information.

[0072] Establish a connection channel with the associated system for storing personal guarantee information, send the basic data set to the associated system, and create a storage space for the corresponding personal guarantee information in the associated system with the insured's name in the basic data set as the index.

[0073] Generate separate records based on the document number field, and associate the personal guarantee information with the name of the insured. For multiple pieces of personal guarantee information under each insured, record them separately in a list form, and sort the personal guarantee information according to the guarantee effective date and the guarantee expiration date.

[0074] In this embodiment, in order to accurately match the insurance policy corresponding to the claim settlement materials, personal guarantee information including the policy number, insurance type, personal guarantee effective date, personal guarantee expiration date, insurance company, underwriting insurance institution, and applicant name information is obtained from the associated system or interface according to the person's name, document type, and document number. The obtained personal guarantee information is stored according to the dimension of the insured's name. The recorded information is the name, document type, and document number. For example, (Zhang San, ID card, 11223344556677889). Each person generates a separate record and stores it according to the uniqueness of the document number. Under each insured, the obtained personal guarantee information is recorded in a list form. For example, (policy number, Zhang San, 11223344556677889, guarantee effective date 00:00:00 on November 1, 2023, guarantee expiration date 23:59:59 on October 31, 2024, XX Insurance Company, XX Branch of XX Insurance Company, XXX Co., Ltd.), indicating that XXX Co., Ltd. insured Zhang San with the document number 11223344556677889. Zhang San's guarantee effective date is 00:00:00 on November 1, 2023, and the guarantee expiration date is 23:59:59 on October 31, 2024. The insurance company is XX Insurance Company, and the underwriting insurance institution is XX Branch of XX Insurance Company. If there are multiple guarantee records under one insured, each guarantee is recorded separately.

[0075] In this embodiment, establish the association relationship between the materials to form a data chain, specifically including:

[0076] Traverse the list of claim settlement material files. For each claim settlement file record that is completely identified (the identification completeness is 100%), extract and classify the claim settlement materials in the claim settlement file record according to the preset material classification rules. For example, for a claim settlement file, extract the ID card-related information (name, document number, etc.), outpatient invoice information (invoice number, visit date, etc.) separately and store them in different data containers for subsequent association operations;

[0077] Obtain the associated information required for the association rules from the extracted claim settlement materials. According to the association rules and the extracted associated information, perform the association matching between the claim settlement materials. For example, the consultation date of the outpatient invoice is May 1, 2024, which is associated with the consultation time of May 1, 2024 in the outpatient medical record. The inpatient number of the inpatient invoice is associated with the inpatient numbers of the discharge summary and the expense list, and they are combined one by one to form a data chain of materials based on a certain key information.

[0078] Based on the matching results, verify the association relationship between the claim settlement materials, judge the effective association between the claim settlement materials, and integrate the verified material association relationship to generate the corresponding material association matching data chain recorded in a single claim settlement file.

[0079] In this embodiment, according to the identification of the material file list, when all materials have been identified, that is, when the identification of a claim settlement file in the claim settlement file list is 100% complete, the operation of intelligently creating a claim settlement form can be carried out. Match the content corresponding to each claim settlement material identified under the claim settlement material file with the rules of the claim settlement application to judge whether a new claim settlement form can be created and automatically mark the claim settlement items or associated claim settlement forms.

[0080] In this embodiment, judging the effective association between the claim settlement materials specifically means: for outpatient medical records and inpatient medical records, extract the disease information recorded therein. Set the disease matching rules. When the diseases are exactly the same or the similarity reaches a certain threshold (for example, 80%, which can be adjusted according to actual business needs), it is determined that there is an effective association between these two medical records. If the association condition is not met, check whether other preset association rules are satisfied. If none of them are satisfied, it is determined that there is a problem with the association of this claim settlement file in this link, and the subsequent steps can be suspended and the user can be prompted to check the accuracy of the uploaded materials to avoid subsequent matching failures caused by material errors.

[0081] In this embodiment, judging the claim settlement items specifically includes:

[0082] Read the preset claim settlement item material matching rules from the claim settlement form database, and determine the judgment criteria and required materials for each claim settlement item based on the claim settlement item category;

[0083] Apply the trained claim settlement item material matching model to the actual claim settlement application. Traverse each claim settlement material in the data chain. For each claim settlement item, check the integrity of the materials required for this item in the data chain, and screen out the set of claim settlement items that meet the conditions;

[0084] The claim settlement item material matching model can judge the claim settlement items according to the material information and association rules in the data chain, and automatically generate the corresponding claim settlement item list;

[0085] Determine whether there are special cases in the set of claim items. Sort out the set of possible application items after the special case judgment and processing, remove duplicate or ineligible items, and record the list of claim materials corresponding to each item (such as the hospitalization medical item corresponds to materials such as hospitalization invoices and discharge summaries).

[0086] In this embodiment, based on insurance claim practice, the claim item data matching model defines the claim items under the claim in a modelized manner. The claim items and the corresponding claim application materials need to be constructed as follows in a systematic model:

[0087]

[0088] For the identified materials, considering the claim materials generated by a single claim accident and the needs met by the division of claim items and the corresponding claim materials, automatically classify and match and associate the corresponding claim materials after the claim item judgment. For example, according to the above example of claim materials, if the system rules determine that there are hospitalizations and outpatient visits, three claim items of hospitalization allowance, hospitalization expense reimbursement, and outpatient expense reimbursement are formed correspondingly. At the same time, the identity card, bank card, outpatient invoice, outpatient medical record, hospitalization invoice, hospitalization medical record, discharge summary, expense list, inspection and test materials.

[0089] In this embodiment, the special cases specifically include: for the major disease claim item, after completing the basic material matching, check whether there is a record of the insured's previous medical history in the claim materials. If there is a relevant record, determine whether the currently applied major disease is related to the previously recorded disease (such as whether it is a recurrence or complication of the same disease). If there is a relationship and it does not meet the claim conditions (such as the insurance terms stipulate restrictions on previous diseases), then exclude this claim item; if there is no relationship or it meets the claim conditions, then retain this item in the set of possible application items.

[0090] In this embodiment, determining whether to generate a claim form or associate a claim specifically includes:

[0091] Extract the medical treatment time information related to the claim items in the claim item set from the data chain (such as the medical treatment date on the outpatient invoice or hospitalization invoice), and compare it with the effective date and expiration date of the guarantee in the personal guarantee information;

[0092] If the medical treatment time is within the guarantee period, it is determined that the time match is successful, and the subsequent insurance type matching is continued; if the medical treatment time is not within the guarantee period, it is directly determined that it does not meet the claim conditions, and the insurance type matching is no longer carried out, and the reason for the time mismatch is recorded to provide a basis for subsequent queries and feedback;

[0093] Obtain the policy insurance type in the personal guarantee information (such as group insurance, personal insurance, etc.), and compare it with the insurance type required by the claim item. For example, if the claim item is a group insurance claim item, check whether the policy insurance type is group insurance;

[0094] If the insurance types match, continue to the next step of judgment; if the insurance types do not match, it is determined that the claim conditions are not met, record the reason for the insurance type mismatch, and stop the subsequent judgment process;

[0095] Query in the claim form database according to the policy number corresponding to the claim item and the extracted medical treatment time. If a claim form record with the same medical treatment time and policy number is found, it is determined that the claim data and the corresponding data group are associated with the corresponding claim form, and record the association information (such as the associated claim form number, association time, etc.); if no relevant record is found, generate a new claim form to prepare for the subsequent claim form generation operation;

[0096] Record the judgment result (generate a claim form, associate a claim form, or do not meet the claim conditions) in a specific field of the claim file, and feedback the judgment result to the user by means of message push or query interface display, etc.; if there is data interaction between this system and other systems (such as the core business system of an insurance company), send the judgment result to other systems according to the established data interface specification to achieve data flow and collaborative processing of business.

[0097] In this embodiment, extract the medical treatment time (defined as the accident occurrence time in insurance claims) information in the claim materials from the claim items and the corresponding material chains generated by the user, and match it with the personal insurance period. If the corresponding accident occurrence time is within the time range of the personal guarantee period, it meets the time rule, otherwise it does not meet the time rule; if the insurance type of the policy (policy number: 123456789) corresponding to the personal guarantee is not group insurance, it does not meet the insurance type matching rule. For example, the medical treatment time of the outpatient invoice extracted from the claim materials is May 1, 2023, and the personal guarantee period is recorded as 0:00:00 on April 1, 2023 to 23:59:59 on March 31, 2024. At the same time, the insurance type of the policy corresponding to the personal guarantee is group insurance, then the match is successful and a claim form can be generated.

[0098] Under the condition of determining that a claim form can be generated, if the corresponding accident time and policy insurance type match and there is an existing claim form record, it is determined that the claim information and the corresponding data group are associated with the corresponding claim form. For example, the visit time of the outpatient invoice extracted from the claim information is May 1, 2023, and the personal protection period record is from 0:00:00 on April 1, 2023 to 23:59:59 on March 31, 2024. At the same time, the policy insurance type corresponding to the personal protection is group insurance, then the match is successful and a claim form can be generated; at the same time, it is found that there is an existing claim record with a visit time of May 1, 2023 and a policy number of 123456789, then the judgment corresponding to this claim information is that it can be associated with the claim form.

[0099] In this embodiment, according to a single claim information, including ID card, bank card, outpatient invoice, inpatient invoice, outpatient medical record, inpatient medical record, discharge summary, classification of inspection and test, and information identified by the corresponding claim information, data associations between the information are constructed, and then a data chain is generated. A claim item information matching model is constructed. The claim items are judged according to the data chain generated from the claim file. Through the data chain and according to the claim item model, the associations of the collected data under all claim file information and the determination of the claim items are obtained, and the key information and data integrity of the data chain can be quickly queried, providing a data basis for quickly and intelligently generating claim application forms for all claim information submitted by users.

[0100] To better implement the intelligent claim application method based on claim service management, please refer to Figure 2 , the present invention provides an intelligent claim application system based on claim service management, including:

[0101] A user information acquisition module, configured to determine a claim information file list of the insured based on the information uploaded by the user, and extract the corresponding claim information and corresponding key information based on the accident information of the insured;

[0102] A relevance calculation module, configured to construct data associations between claim information according to association rules, match the accident information of the insured with the policy information, and judge whether to generate a new claim form or associate with an existing claim form based on the matching result;

[0103] The relevance calculation module further includes: quantitatively evaluating the matching degree of the accident information of the insured and the policy information, calculating the association value of the corresponding claim information and the policy information based on the evaluation result. If the calculated association value is high, it indicates that the matching degree of the claim information and the policy is high, and it is more in line with the conditions for generating a claim form or associating with a claim form; otherwise, the information needs to be further verified or supplemented. At the same time, for multiple claim items or policies, they are sorted according to the size of the association value, and the claim applications with high association values are processed preferentially;

[0104] The associated claim recommendation module is configured to recommend creating a new claim form and an associated claim form to the user when the judgment result meets the condition for generating a claim form, guiding the user to complete the claim application operation.

[0105] In this embodiment, through the user information acquisition module, the relevance calculation module, and the associated claim recommendation module, the automation and intelligence of claim applications are realized. A claim data file is established based on the materials uploaded by the user, key information is extracted, data associations between claim materials are constructed according to association rules, and the association value between the claim materials and the policy information is calculated, so as to judge whether to generate a new claim form or associate an existing claim form. This can effectively improve the claim efficiency and accuracy, reduce manual intervention, enhance the user experience, and provide an efficient and convenient claim service solution for the insurance industry.

[0106] The above is only a preferred specific embodiment of the present invention, but the protection scope of the present invention is not limited thereto. Any person skilled in the art within the technical scope disclosed by the present invention, according to the technical solution and inventive concept of the present invention, making equivalent replacements or changes, shall be covered by the protection scope of the present invention.

Claims

1. An intelligent claim application method based on claim service management, characterized in that Including: Obtain the user's identity information and upload the relevant claim application materials, establish a claim materials file list based on the claim materials uploaded by the user to the cloud, classify the claim materials and identify the corresponding key information; Based on the recognition result, obtain the personal guarantee information and the corresponding policy information according to the associated system, and generate a personal guarantee information list; According to each claim material recognized in the claim materials file list, construct the association relationship between the materials to form a data chain; And judge the claim items according to the data chain, match the personal guarantee information according to the claim items and the corresponding data chain, and judge whether to generate a claim form or an associated claim form according to the time matching and insurance type matching rules; Generate a claim form under the condition of meeting the requirements according to the judgment result, automatically generate a claim application form, and associate the corresponding claim materials.

2. The intelligent claims application method based on claims service management according to claim 1, wherein Obtain the user's identity information and upload the relevant claim application materials, specifically including: The user uploads the personal identity information and claim-related materials to the cloud; Extract the name of the insured from the claim-related materials uploaded by the user, use the name of the insured as the file storage name established in the cloud, randomly generate a unique identifier for the file storage, and at the same time associate the information such as the name of the insured, ID number, data upload platform, number of data sheets, creator, and creation time, and store them in the cloud to form a claim materials file list; In the claim materials file list, present the claim materials information submitted each time in the form of a separate record, and obtain all the file materials records submitted by the user for the insured through the claim file list.

3. The intelligent claim application method based on claim service management according to claim 2, wherein Classify the claim materials and identify the corresponding key information, specifically including: Preprocess the claim materials image uploaded by the user, input the preprocessed claim materials image into a pre-trained classification model, classify according to the claim materials image features, and determine the type of the claim materials image; Determine the key information area of each type of claim material, segment the claim materials image into multiple areas based on the image segmentation technology, and match the segmented areas with the key information areas to determine the type of key information corresponding to each area; Based on the matching result, convert the text in each area into text information, determine it as the key information of the claim materials uploaded by the user, and determine the corresponding key information type.

4. The intelligent claim application method based on claim service management according to claim 3, wherein Generate a personal guarantee information list, specifically including: Based on the file record format in the claim materials file list, locate the fields of the name of the insured, ID type, and ID number stored in each claim materials file, and integrate and generate a basic data set for querying personal guarantee information; Establish a connection channel with the associated system that stores personal guarantee information, send the basic data set to the associated system, and create a storage space for the corresponding personal guarantee information in the associated system with the name of the insured in the basic data set as the index; Generate a separate record according to the ID number field, associate the personal guarantee information with the name of the insured, and record the multiple personal guarantee information under each insured in the form of a list respectively, and sort the personal guarantee information according to the guarantee effective date and guarantee expiration date.

5. The intelligent claim application method based on claim service management according to claim 1, characterized in that, Build the association relationships between materials to form a data chain, specifically including: Traverse the list of claim settlement material files. For each completely identified claim settlement file record, extract the claim settlement materials in the claim settlement file record according to the preset material classification rules; Obtain the association information required by the association rules from the extracted claim settlement materials, and perform association matching between the claim settlement materials according to the association rules and the extracted association information; Verify the association relationships between the claim settlement materials based on the matching results, judge the valid associations between the claim settlement materials, and integrate the verified material association relationships to generate the corresponding material association matching data chain under a single claim settlement file record.

6. The intelligent claims application method based on claims service management according to claim 5, wherein Judge the claim items, specifically including: Read the preset claim item material matching rules from the claim settlement form database, and determine the judgment criteria and required materials for each claim item based on the claim item category; Apply the trained claim item material matching model to the actual claim settlement application, traverse each claim settlement material in the data chain, and for each claim item, check the integrity of the required materials for the item in the data chain to filter out the set of eligible claim items; Judge whether there are special circumstances in the set of claim items, sort out the set of possible application items after the special circumstances judgment process, remove duplicate or ineligible items, and record the claim settlement material list corresponding to each item.

7. The intelligent claims application system based on claims service management according to claim 6, wherein Judge whether to generate a claim settlement form or associated claim settlement, specifically including: Extract the medical treatment time information related to the claim items in the claim settlement set from the data chain, and compare it with the effective date and expiration date of the guarantee in the personal guarantee information; If the medical treatment time is within the guarantee period, it is determined that the time match is successful, and the subsequent insurance type matching is continued; if the medical treatment time is not within the guarantee period, it is directly determined that the claim settlement conditions are not met, the insurance type matching is no longer performed, and the reason for the time mismatch is recorded; Obtain the insurance type of the insurance policy in the personal guarantee information and compare it with the required insurance type of the claim item; If the insurance types match, continue to the next judgment; if the insurance types do not match, it is determined that the claim settlement conditions are not met, the reason for the insurance type mismatch is recorded, and the subsequent judgment process is stopped; Query in the claim settlement form database according to the policy number corresponding to the claim item and the extracted medical treatment time. If a claim settlement form record with the same medical treatment time and policy number is found, it is determined that the claim settlement materials and the corresponding data group are associated with the corresponding claim settlement form, and the association information is recorded; if no relevant record is found, a new claim settlement form is generated.

8. The intelligent claim application system based on claim service management according to claim 1, wherein Automatically generate a claim settlement application form, which also includes: for the materials and data chain that meet the conditions of the associated claim settlement form, display the corresponding claim settlement application form information in terms of the matching policy number. After the user operates, the association operation is completed to realize the association between the claim settlement materials and the existing claim settlement application form.

9. An intelligent claims application system based on claims service management, which is applied to the intelligent claims application method based on claims service management as described in claim 1, is characterized in that, Including: A user information acquisition module configured to determine the list of claim settlement material files of the insured based on the materials uploaded by the user, and extract the corresponding claim settlement materials and corresponding key information based on the accident information of the insured; The relevance calculation module is configured to construct data associations between claim settlement materials according to association rules, match the accident information of the insured with the policy information, and determine whether to generate a new claim settlement form or associate with an existing claim settlement form based on the matching result; The associated claim settlement recommendation module is configured to recommend a new claim settlement form and an associated claim settlement form to the user and guide the user to complete the claim settlement application operation when the judgment result meets the conditions for generating a claim settlement form.

10. The intelligent claims application system based on claims service management according to claim 9, wherein The relevance calculation module further includes: quantitatively evaluating the matching degree of the accident information of the insured with the policy information, calculating the association value of the corresponding claim settlement materials with the policy information based on the evaluation result, and at the same time, sorting multiple claim items or policies according to the size of the association value and giving priority to processing claim settlement applications with high association values.

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