Direct Payment System Design Based On The Edc's Health Insurance Claims

With the deepening of China's economic reform system, and the execution of the Social Security Systems and the Medical Services Systems reform, Commercial Health Insurance is brought into focus. But the unclearness about the claim procedure of the medical department and the insurant greatly limits the popularization of insurance, hinders its effect, because they have to provide the materials for many times in the process of claims. It is the Medical Claims Direct Bulling System which applies the EDC technology (Electronic Data Capture, also known as electronic data capture terminal) that builds an information channel between the insurance companies, the medical department and the insurant, realizes the real-time exchange of information and the real-time processing of claims, and enhances the users' satisfaction.First of all, the current situation of the Carelink electronic medical claims system is analyzed, the importance of the real-time claim processing is stressed, and the feasibility of EDC technology in the Carelink electronic medical claims system upon the analysis of the business characteristics and available resources of the triple (the medical department, the insurant and the insurance company) who take part in the claims is discussed. On that basis, the requirements and the business process of the Carelink electronic medical claims system are analyzed and the system architecture is constructed. Then the core subsystems such as the claims eligibility verification, claims review, claims settlement and other core subsystems in detail are designed. Meanwhile, how to use real-time and security transmission of claims information of EDC technology in the core subsystems are discussed seriously. Finally, the scalability and the benefits of the system are analyzed.