IC36 M0ck Test Sample 1
IC36 Health Insurance Claims Management focuses on efficient claim processing, fraud control, standardized medical coding, and cost containment. WHO developed the International Classification of Diseases (ICD) codes, while treatment procedures are coded using Current Procedural Terminology (CPT). TPAs facilitate cashless and reimbursement claims through network hospitals and membership cards. Strict claims management, wellness programs, and case management help reduce claim costs and improve customer outcomes. Health insurers face challenges from fraudulent and unnecessary hospitalizations. Understanding common medical conditions, claim adjudication processes, and documentation requirements is essential for effective health insurance claims administration and improved policyholder service.
1. WHO developed codes commonly known as:
a) International Classification of Diseases Codes
b) International Disease Procedure Codes
c) Indian Classification of Diseases Codes
d) Immunity Classification Codes
2. The TPA membership card generally includes:
a) Name
b) Age
c) Policy Number
d) Previous Insurance Policy Number
3. High loss ratios in health insurance are mainly due to:
a) Low premium rates
b) High population growth
c) Fraudulent and unnecessary hospitalization claims
d) Increased awareness
4. Red patches on the hands and face in children are commonly associated with:
a) Cellulitis
b) Impetigo
c) Rhinitis
d) Pulpitis
5. Medical procedure codes are known as:
a) Current Procedural Terminology (CPT) Codes
b) Common Practice Treatment Codes
c) Clinical Procedure Tracking Codes
d) Classified Procedure Treatment Codes
6. A disadvantage of cashless treatment is:
a) Limited network hospitals
b) No documentation required
c) Lower sum insured
d) Higher premium
7. Wellness programs without periodic monitoring may:
a) Improve profitability
b) Reduce claims automatically
c) Have limited impact on cost control
d) Increase coverage limits
8. Which organ is considered vital from an insurance perspective due to chronic ailments?
a) Pancreas
b) Appendix
c) Liver
d) Esophagus
9. Which is the largest organ of the human body?
a) Heart
b) Liver
c) Skin
d) Lungs
10. Standardized coding helps to:
a) Reduce premium rates
b) Correlate illnesses with procedures and evaluate costs
c) Increase hospitalization
d) Eliminate exclusions
11. TPA fees are generally not based on:
a) Percentage of premium
b) Approved claim amount
c) Per-member fixed charges
d) Per-service transaction charges
12. Strict claims management involves:
a) Trend analysis of providers
b) Audit and scrutiny of claims
c) Establishing reasonable charges
d) All of the above
13. If the hospital bill exceeds the approved cashless amount, the hospital may:
a) Cancel treatment
b) Seek additional authorization
c) Reject the claim
d) Convert the policy
14. Case management is suitable for groups because:
a) It is cost-effective and easier to monitor outcomes
b) Premiums are always lower
c) Claims are fewer
d) Policies are compulsory
15. Shooting pain from the vertebral column is related to the:
a) Respiratory system
b) Digestive system
c) Nervous system
d) Endocrine system
16. What follows coding in the claims process?
a) Processing and adjudication
b) Policy renewal
c) Underwriting
d) Premium collection
17. Persistent hyperglycaemia due to insulin disorders is called:
a) Cellulitis
b) Diabetes Mellitus
c) Folliculitis
d) Pyelonephritis
18. Treatment at a non-network hospital is generally settled through:
a) Cashless facility
b) Reimbursement process
c) Claim rejection
d) Premium refund
19. Wellness programs can result in:
a) Healthier lifestyles
b) Better customer satisfaction
c) Reduced health risks
d) All of the above
20. Which organization in India maintains repositories to analyze insurance-related coding information?
a) LIC
b) GIC Re
c) Insurance Information Bureau (IIB)
d) National Insurance Academy
