IC36 Mock Test Sample 11
Health Insurance Claims Management involves the systematic handling of health insurance claims from intimation to settlement. It includes verification of policy terms, assessment of admissibility, scrutiny of medical documents, fraud detection, coding of diseases and procedures using ICD and CPT systems, and coordination among insurers, TPAs, hospitals, and policyholders. Effective claims management ensures fair, timely, and accurate claim settlement while controlling costs and preventing abuse. Network providers, cashless facilities, audits, investigations, and proper documentation play significant roles. Understanding medical terminology, provider management, and claim procedures helps improve efficiency, customer satisfaction, and overall healthcare outcomes.
1. What is the primary purpose of investigation during claim processing?
a) Increase hospital charges
b) Examine cause and extent of loss
c) Delay settlement intentionally
d) Promote healthcare services
2. Which provider category includes nurses and specialists?
a) Institutional providers
b) Individual-based providers
c) Diagnostic providers
d) Emergency providers
3. The length of hospital stay for a diabetic patient is generally ______ than a non-diabetic patient.
a) Less
b) Equal
c) More
d) Uncertain
4. Laparoscopy is commonly associated with which body system?
a) Respiratory system
b) Circulatory system
c) Gastrointestinal system
d) Endocrine system
5. RSBY is primarily designed for:
a) Corporate employees
b) Senior citizens only
c) People below the poverty line
d) International travelers
6. ICD-9-CM was officially used for hospital diagnoses and procedures in:
a) India
b) Australia
c) United States
d) Belgium
7. Bacillary dysentery mainly affects the:
a) Nervous system
b) Digestive system
c) Endocrine system
d) Respiratory system
8. Which card is issued under the RSBY scheme for availing benefits?
a) Voter ID Card
b) Aadhaar Card
c) Ration Card
d) Biometric Card
9. A Day Care Centre should operate under the supervision of a:
a) Pharmacist
b) Registered medical practitioner
c) Insurance surveyor
d) Laboratory technician
10. Medical coding assists insurers in:
a) Product design
b) Estimating healthcare costs
c) Assessing disease burden
d) All of the above
11. Surgical removal of the spleen is known as:
a) Appendicectomy
b) Splenectomy
c) Cholecystectomy
d) Transplantation
12. Which policy provides financial protection against accidental injuries?
a) Fire Policy
b) Marine Policy
c) Personal Accident Policy
d) Burglary Policy
13. Providers agreeing to pre-negotiated treatment rates form a:
a) Wellness Network
b) Emergency Network
c) Preferred Provider Network
d) Specialist Forum
14. Which practice may contribute to claim inflation by network providers?
a) Unnecessary investigations
b) Upgrading room category
c) Excess physician visits
d) All of the above
15. Cyanosis is commonly associated with disorders of the:
a) Digestive system
b) Respiratory system
c) Urinary system
d) Reproductive system
16. Which factor has the most direct influence on quality of healthcare?
a) Hospital location
b) Number of beds
c) Medical professionals' competence
d) Parking facilities
17. Which of the following is NOT a common fraud pattern in group health insurance?
a) Bill inflation
b) Impersonation
c) Claim manipulation
d) Routine vaccination claims
18. Investigation in claims management helps in:
a) Establishing fraud indicators
b) Determining nature of loss
c) Collecting supporting evidence
d) All of the above
19. Clusters of pancreatic cells responsible for hormone production are called:
a) Acini
b) Nephrons
c) Islets
d) Alveoli
20. Special network providers are generally selected based on:
a) Ethical practices
b) Reasonable tariffs
c) Willingness to partner with payers
d) All of the above
