Design And Implementation Of Health Insurance Claims System Based On Web Services

Shanghai Puyong Health Insurance Company, Ltd. is a professional insurance company, majoring in managing commercial health insurance business. The information level of the company is not so advanced that claims processing management is basically managing heavy manual work with low efficiency and causing a lot of problems for the operators. While Huadao Insurance, the partner company of Puyong, owns an advanced claims system which is professional in auto-adjudication and risk management. Therefore, it becomes Puyong’s urgent goal to integrate two systems in order to realize auto-adjudication, reduce loss ratio, increase processing efficiency and improve claims correctness and accuracy.First of all, the current situation of Puyong’s claims processing system is analyzed in the paper. The difficulties and problems met when integrating with Huadao’s system and the necessity of using Web Services as the development solution are talked. Based on these, the main functions (bills analysis, benefit adjudication, etc.) and core processes of Puyong’s claims processing system (bills capture, auto-adjudication, manual review, etc.) is further illustrated. Then the MVC framework of Puyong’s claims processing system is discussed. The claims capture sub-system, benefit adjudication sub-system and the integration with Huadao’s claims system based on Web Services are designed in details. As a result, quick and accurate auto-adjudication can be achieved, the operating TAT and claims correctness and accuracy can be increased. Finally the stability and extensibility issue of Puyong’s claims processing system are analyzed.