Diseño, desarrollo e implantación de un sistema de información para llevar a cabo la administración de reclamos del seguro INS Medical en el Departamento de Accidentes y Salud del Instituto Nacional de Seguros
Archivos
Fecha
2005
Autores
Chaves Moya, Nattanahel Alberto
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Editor
Universidad Nacional (Costa Rica)
Resumen
El sistema permitirá a los funcionarios del Departamento de Accidentes y Salud del Instituto Nacional de Seguros (INS) administrar la información concerniente a las solicitudes de indemnización que presentan los proveedores o asegurados del producto llamado INS Medical, cuya finalidad es cubrir los gastos médicos en que incurran los asegurados a consecuencia de accidentes o enfermedades cubiertas por este contrato de seguro. La solicitud de indemnización puede ser presentada por el propio asegurado o por el proveedor que te brindó el servicio, por ejemplo, una clínica o un laboratorio privado. Dicha solicitud incluye las facturas que hacen constar la prestación de algún servicio o la compra de algún producto. El sistema permitirá registrar la información contenida en las facturas y asociarlas con un expediente electrónico de reclamo, así como con la información de la póliza que está almacenada en los sistemas institucionales tales como el número de póliza, vigencia del seguro, monto asegurado, etc. Para lograr esta asociación Se creó una interfaz de comunicación que permitirá interactuar, de forma automática y transparente para el usuario, con sistemas desarrollados en tecnología AS/400 de IBM. Una vez que la información de las facturas ingresa al expediente electrónico de reclamos, el sistema deberá asistir el proceso de liquidación del reclamo que consiste en determinar el monto a indemnizar de acuerdo a las condiciones del contrato. El sistema, por lo tanto, deberá tomar en cuenta las condiciones generales del contrato de seguros para determinar, por ejemplo, los porcentajes que $e reconocerán por la compra de medicamentos o por las consultas médicas, así como por los diferentes tratamientos que cubre el seguro.
The system will allow the officials of the Department of Accidents and Health of the National Insurance Institute (INS) to manage the information concerning the requests for compensation presented by the providers or insured of the product called INS Medical, whose purpose is to cover the medical expenses in which incurred by the insured as a result of accidents or illnesses covered by this insurance contract. The request for compensation can be submitted by the insured himself or by the provider who provided the service, for example, a clinic or a private laboratory. This request includes the invoices that record the provision of a service or the purchase of a product. The system will allow the information contained in the invoices to be recorded and associated with an electronic claim file, as well as with the policy information that is stored in the institutional systems, such as the policy number, insurance validity, insured amount, etc. To achieve this association, a communication interface was created that will allow users to interact automatically and transparently with systems developed using IBM AS/400 technology. Once the invoice information enters the electronic claims file, the system must assist in the claim settlement process, which consists of determining the amount to be compensated according to the contract conditions. The system, therefore, must take into account the general conditions of the insurance contract to determine, for example, the percentages that will be recognized for the purchase of medicines or for medical consultations, as well as for the different treatments covered by the insurance. sure.
The system will allow the officials of the Department of Accidents and Health of the National Insurance Institute (INS) to manage the information concerning the requests for compensation presented by the providers or insured of the product called INS Medical, whose purpose is to cover the medical expenses in which incurred by the insured as a result of accidents or illnesses covered by this insurance contract. The request for compensation can be submitted by the insured himself or by the provider who provided the service, for example, a clinic or a private laboratory. This request includes the invoices that record the provision of a service or the purchase of a product. The system will allow the information contained in the invoices to be recorded and associated with an electronic claim file, as well as with the policy information that is stored in the institutional systems, such as the policy number, insurance validity, insured amount, etc. To achieve this association, a communication interface was created that will allow users to interact automatically and transparently with systems developed using IBM AS/400 technology. Once the invoice information enters the electronic claims file, the system must assist in the claim settlement process, which consists of determining the amount to be compensated according to the contract conditions. The system, therefore, must take into account the general conditions of the insurance contract to determine, for example, the percentages that will be recognized for the purchase of medicines or for medical consultations, as well as for the different treatments covered by the insurance. sure.
Descripción
Chaves Moya, N. A. (2005). Diseño desarrollo e implantación de un sistema de información para llevar a cabo la administración de reclamos del seguro INS Medical en el Departamento de Accidentes y Salud del Instituto Nacional de Seguros. [Tesis de Licenciatura]. Universidad Nacional, Costa Rica.
Palabras clave
INSTITUTO NACIONAL DE SEGUROS (COSTA RICA), SISTEMAS DE INFORMACION PARA LA GESTION, INGENIERÍA DE SISTEMAS, SEGUROS, SYSTEMS ENGINEER, INSURANCE