Expert Systems in the Insurance Indstry在保险业专家系统.pptVIP

Expert Systems in the Insurance Industry Uses of Expert Systems in Insurance Underwriting Policy Matching Benefit Querying Claim Processing BenInq A Benefit Inquiry tool BenInq helps customer service representatives determine what medical services a customer is covered for Why? Insurance companies have many products Better searching More detailed information Easier to modify How It Works Knowledge representation Rule Representation Reasoning Methods Knowledge Representation Services Benefits Coverage Business Rules Cost sharing Access Administrative and Medical External Representation Both Services and Benefits are organized in semantic networks Services are organized in a multiple-inheritance hierarchy Benefits are shown by using ‘covered’ and ‘excluded’ links between benefits and services nodes Internal Representation Represented as a Formula-Augmented Semantic Network (FAN) A FAN allows us to attach rules to nodes using well formed formulae These rules allow us to apply regulations to each of the nodes Internal Representation Rule Representation Rules are represented using well-formed formulae translates to: Patients in Drug Rehabilitation programs lose all rehab benefits for one year if they are non-compliant Reasoning Methods Determining if a service is covered or excluded by a benefit Determining which rules apply to a node Reasoning Methods Reasoning Methods Well-Formed Formula Inheritance problem Since nodes can inherit from multiple parents which rules apply? Maximally Consistent Subsets (mcs) Preferred Maximally Consistent Subsets (pmcs) PMCS First remove conflicted and pre-empted edges Then, starting at the focus node traverse upwards At each node take the pmcs of the set computed so far and the wff’s at the current node Implementation System comprises of two tools inquiry tool authoring tool Implemented using VisualAge Smalltalk Usage Two main user groups Customer Service Representatives (CSR’s) Policy Modifiers (PM’s) CSR’s View Shows services, cove