IC36 Mock Test Sample 14
Third Party Administrators (TPAs) play a vital role in servicing health insurance customers by facilitating cashless hospitalization, registering and processing claims, scrutinizing documents, coordinating with hospitals, and recommending claim settlements. Healthcare services are classified into primary, secondary, and tertiary care depending on the complexity of treatment. Fraud prevention, investigations, and surveillance systems are essential to control claim costs and protect insurers from financial losses. Providers are evaluated based on quality standards, infrastructure, and adherence to agreed procedures. Effective claim management ensures timely assistance to policyholders while maintaining transparency, efficiency, and compliance with insurance regulations.
Q1. A TPA is a company or a firm that is created exclusively for?
a) Processing claims of insurance industry
b) Negotiating rates and tariff with the hospitals
c) Arranging cashless service facility for the members of the TPA
d) Servicing of health insurance customers
Q2. The criteria for number of beds can be waived in case of ________.
a) Nursing Home
b) Hospital in rural area
c) Hospital in Urban area
d) Day Care Centers
Q3. Instead of checking each case against the fraud trigger, developing software to avoid excess cost involved is called:
a) Reports to Track
b) Red Alert Surveillance
c) Red Alert Sound
d) Red Alert Scanning
Q4. The care provided by super specialists in facilities equipped for non-routine care is termed as:
a) Routine Care
b) Primary Care
c) Secondary Care
d) Tertiary Care
Q5. Which activity is the first step in TPA claim handling?
a) Receive the claim documents
b) Scrutinize the papers
c) Pass recommendation for payment
d) Check tariffs and policy terms
Q6. ____________ is also known as opportunistic fraud.
a) Legitimate Fraud
b) Soft Fraud
c) Hard Fraud
d) External Fraud
Q7. Improper functioning of the respiratory system can result in:
a) Leukaemia
b) Lymphoma
c) Deviated Nasal Septum
d) Ureteric Stone
Q8. Enrolment is the activity of __________ members into the TPA's service.
a) Adding
b) Engaging
c) Admitting
d) Listing
Q9. In a town with a population of around 10 lakh people, the minimum number of hospital beds should be:
a) 5
b) 10
c) 15
d) 20
Q10. Diagnostic services, emergency services, ICU facilities, and preventive care are part of:
a) Primary Services
b) Provider Scope of Services
c) TPA Functions
d) Insurance Operations
Q11. Insurance __________ refers to any act performed with the intent to obtain payment from the insurer without entitlement.
a) Claim
b) File
c) Fraud
d) Error
Q12. Which statement about the Insurance Regulator is incorrect?
a) Regulates insurance business
b) Acts as a TPA for health claims
c) Protects policyholder interests
d) Ensures insurer solvency
Q13. Controlling fraud and unnecessary claims leads to:
a) Unsatisfied customers
b) Reduced claims costs
c) Higher hospitalization rates
d) Expansion of fraud
Q14. The word closest in meaning to 'plenary' is:
a) Partial
b) Restricted
c) Absolute
d) General
Q15. The process of verification of case facts in the field is called:
a) Inspection
b) Detection
c) Investigation
d) Review
Q16. Registration of claim refers to:
a) Entering claim details into the system and generating a reference number
b) Recording only the claimant's name
c) Recording only settled claims
d) Issuing a TPA identity card
Q17. The word closest in meaning to 'truant' healthcare providers is:
a) Fraud
b) Absent
c) Cheat
d) Hoax
Q18. Which statement correctly describes fraud?
a) Fraud is an intentional act
b) Fraud deceives others for gain
c) Fraud may cause financial loss
d) Fraud is always accidental
Q19. The brain stem is comprised of which structures?
a) Frontal Lobe, Occipital Lobe, Pons
b) Pons, Medulla, Midbrain
c) Occipital Lobe, Medulla, Midbrain
d) Frontal Lobe, Midbrain, Medulla
Q20. In an emergency requiring cashless treatment, the insured should first:
a) Provide complete past medical history only
b) Approach the hospital with TPA details, membership number, and insurer information
c) Wait for approval before entering the hospital
d) Shift to another hospital immediately
