Health Insurance Claim Data Structure
Health insurance claim data originates from various health insurance information systems, designated medical institution HIS systems, and settlement centers. This data typically exists in structured or semi-structured formats like XML, JSON, or CSV files. Data updates frequently. It covers daily outpatient and inpatient expense details, drug and consumable codes, treatment item codes, and disease diagnosis codes. Document structures are complex, containing numerous nested fields such as cost composition, payer information, and patient basic information. Field names often include specific industry acronyms. Units involve Chinese Yuan (RMB), quantity units (e.g., box, piece), and frequency units (e.g., times/day). Standards may vary by region.
Constraints Imposed by These Characteristics on "HTTP Interface and External Systems"
The high-frequency updates of health insurance claim data require HTTP interfaces to support efficient concurrent processing and low-latency responses. Complex document structures and nested fields necessitate careful consideration of data parsing depth and accurate field mapping during interface design to prevent data loss or misalignment. Diverse field units and regional variations require standardized processing at both the data transmission and reception ends to ensure data consistency. Sensitive patient information and settlement amounts demand high data transmission security, requiring encrypted transmission protocols and strict authentication. The interface must support file upload functionality for attachments such as health insurance claim forms.
Configuration Guidelines
| Configuration Item | Recommended Value | Rationale |
|---|---|---|
UPLOAD_FILE_MAX_SIZE | 50 MB | Health insurance claim forms, images, and other attachments can be large; this value covers most scenarios. |
PARSE_FILE_TIMEOUT_SECONDS | 300 seconds | Complex or large files require longer parsing times; this allows sufficient processing time. |
maxContext | 32000 | Health insurance claim data has strong contextual relevance and requires accommodating significant historical information. |
Chunk size | 800 characters | Health insurance claim detail items are typically short, ensuring semantic completeness. |
Recall count | 15 entries | Improves the accuracy of matching relevant settlement rules and policies. |
Similarity threshold | 0.75 | Health insurance codes and descriptions have some similarity; this value effectively filters results. |
Common Pitfalls
- HTTP interface returns status code 500 or 502: This typically indicates a backend service timeout or gateway configuration issue, often due to the large volume of health insurance data causing processing bottlenecks.
- After uploading a file, knowledge base content is incomplete or some fields are missing: The file parser did not correctly handle complex table structures or nested fields within health insurance claim documents.
- After calling the API, retrieval results contain a large number of irrelevant health insurance policies or codes: The number of recalled items or similarity threshold is set improperly, failing to effectively focus on specific health insurance claim knowledge.
Verification of Configuration
- Upload a simulated health insurance claim document via API, including various settlement types and attachments. Verify the completeness and accuracy of all expense details, codes, and policy references in the knowledge base.
- Initiate queries for specific health insurance claim scenarios using the API. Compare the returned knowledge points with expectations and evaluate their accuracy.
- Simulate concurrent upload and query requests during peak hours. Monitor HTTP interface response times to confirm results are returned within the specified timeframe without timeout errors.
The values provided are common starting points and should be measured against the reader's own samples.
Question material comes from public community discussions. Configuration values are common starting points and should be measured against your own samples. Verified on 2026-09-21.