IC36 M0ck Test Sample 2
IC36 Health Insurance Claims Management emphasizes efficient claim processing, provider management, medical audits, and cost containment. TPAs verify treatment details, tariff adherence, and policy coverage before recommending claim payments. Clinical audits evaluate infrastructure, treatment processes, and outcomes to improve healthcare quality. Standardized medical and pharmaceutical coding ensures consistency in claim adjudication and data analysis. Preventive care programs and provider networks support effective claims management. Understanding body systems, infections, diagnostic tests, and disease classifications helps insurance professionals assess claims accurately. Proper documentation, policy updates, and internal reporting contribute to transparency and efficient health insurance administration.
1. Fill in the blank: The heart of claim processing is whether the claim is ________ under the policy.
a) Suitable
b) Paid
c) Payable
d) Admissible
2. TPA verifies all the following except:
a) Identity of the patient
b) Treatment provided for the approved condition
c) Adherence to agreed tariff rates
d) Vaccination expenses of the family
3. Provider Management includes all except:
a) Checking provider credibility
b) Negotiating tariffs and discounts
c) Medical audits of providers
d) Premium collection
4. Which of the following is NOT part of the upper respiratory tract?
a) Nasal cavity
b) Pharynx
c) Larynx
d) Bronchial tree
5. The synonym of the word "Non-Inclusion" is:
a) Involvement
b) Incorporation
c) Omission
d) Addition
6. Common signs of infection include:
a) Redness
b) Swelling
c) Pain
d) All of the above
7. The first step toward claims cost containment is:
a) Negotiating tariffs
b) Building provider networks
c) Promoting preventive care programs
d) Medical audits
8. Insurers may require claim data from TPAs for:
a) Liability computation
b) Trend analysis
c) Cash flow management
d) All of the above
9. Clinical audit covers:
a) Infrastructure audit
b) Process audit
c) Outcome audit
d) All of the above
10. If a legally changed name is not updated in the policy, the claim may face issues related to:
a) Premium payment
b) Identity verification
c) Sum insured
d) Policy tenure
11. Billing services provided by TPAs include:
a) Standardized billing patterns
b) Capturing diagnosis codes
c) Capturing procedure codes
d) All of the above
12. Hypertensive nephropathy primarily affects the:
a) Liver
b) Kidneys
c) Heart
d) Brain
13. Which of the following is commonly excluded under health insurance policies?
a) Dental treatments
b) Treatments outside India
c) Alcohol-related illnesses
d) All of the above
14. Internal TPA reports generally include:
a) People productivity reports
b) Hospital utilization reports
c) Treatment cost comparisons
d) All of the above
15. Medical professionals should consider ________ while medical coding.
a) Co-morbidities
b) Medical history
c) Interventions
d) All of the above
16. Requests for shortfalls should ideally be raised with a ________ list of requirements.
a) Unified
b) Consolidated
c) Combined
d) Expanded
17. Pulmonary Function Tests help assess:
a) Kidney function
b) Lung performance and gas exchange
c) Insulin production
d) Liver efficiency
18. While selecting providers, insurers consider factors such as:
a) Accessibility
b) Quality of care
c) Geographical location
d) All of the above
19. ________ are used in medical classification to uniquely identify medications.
a) Diagnostic codes
b) Procedural codes
c) Pharmaceutical codes
d) Medical records
20. The study of diseases, their causes, and effects is known as:
a) Anatomy
b) Physiology
c) Pathology
d) Hepatology
