自動化理賠核定

System ↔ System

理賠事件觸發保單查詢、規則引擎、給付計算及付款。

6 個節點 · 5 條連接insurance

eventsystemdbapi

視覺化

理賠申請事件event

從醫療提供者收到 EDI 837 或 API 理賠申請。

↓sequential→ 保單查詢

保單查詢db

查詢被保險人資格、保單詳情及給付明細。

↓sequential→ 承保規則引擎

承保規則引擎system

套用醫療必要性、預先授權及網絡狀態規則。

↓conditional→ 給付計算

給付計算system

計算允許金額、部分負擔、共同保險及已扣除的自付額。

↓sequential→ 付款系統

付款系統api

提交 ERA 835 匯款資料並啟動 EFT/支票付款。

↓sequential→ 給付說明書通知

給付說明書通知api

向被保險人及醫療提供者發送給付說明書。

在編輯器開啟

uc-claims-adjudication.osop.yaml

osop_version: "1.0"
id: "claims-adjudication"
name:"自動化理賠核定"
description:"理賠事件觸發保單查詢、規則引擎、給付計算及付款。"

nodes:
  - id: "claim_event"
    type: "event"
    name: "理賠申請事件"
    description: "從醫療提供者收到 EDI 837 或 API 理賠申請。"

  - id: "policy_lookup"
    type: "db"
    name: "保單查詢"
    description: "查詢被保險人資格、保單詳情及給付明細。"
    timeout_sec: 10

  - id: "rules_engine"
    type: "system"
    name: "承保規則引擎"
    description: "套用醫療必要性、預先授權及網絡狀態規則。"

  - id: "benefit_calc"
    type: "system"
    name: "給付計算"
    description: "計算允許金額、部分負擔、共同保險及已扣除的自付額。"

  - id: "payment"
    type: "api"
    subtype: "rest"
    name: "付款系統"
    description: "提交 ERA 835 匯款資料並啟動 EFT/支票付款。"
    security:
      risk_level: "high"
    retry_policy:
      max_attempts: 3

  - id: "notification"
    type: "api"
    name: "給付說明書通知"
    description: "向被保險人及醫療提供者發送給付說明書。"

edges:
  - from: "claim_event"
    to: "policy_lookup"
    mode: "sequential"
  - from: "policy_lookup"
    to: "rules_engine"
    mode: "sequential"
  - from: "rules_engine"
    to: "benefit_calc"
    mode: "conditional"
    when: "claim.eligible == true"
  - from: "benefit_calc"
    to: "payment"
    mode: "sequential"
  - from: "payment"
    to: "notification"
    mode: "sequential"