Research on intelligent claim model technology based on claim rules

This study is part of the project “Research on intelligent processing of bill documents based on SVM and LD algorithm”. This study addresses the challenges associated with State Grid Corporation's internal process of medical insurance claims, including demanding workload, varying medical insurance policies in different regions, and medical documents with changing formats and unqualified image quality. It innovatively presents a novel insurance claims processing workflow integrated with intelligent techniques. This solution works with an intelligent mechanism for claims process automation, risk management, and business data monitoring, in a bid to transform claims processing into an AI-powered, efficient system. Using this solution, OCR can automatically extract key information, including units and amounts from medical invoices, while with the support of natural language processing, the conditions and prescriptions listed in diagnosis certificates can be analyzed quickly. Furthermore, it thoroughly screens and verifies medical content, prices and other cost details from medical insurance data. The rule-based system that the system hinges on automatically matches insurance claims with insurance policies, making the verification of medical insurance premiums and corresponding compensation faster and more efficient. In addition to reducing labor costs and raising processing efficiency, this technology also allows for an intelligent compensation self-service procedure, which is conducive to enterprises’ transformation into the digital environment and scale both their economic and societal value creation.