IC36 Mock Test Sample 17
Health insurance claim management involves claim intimation, registration, document verification, coding, adjudication, fraud detection, and settlement. Third Party Administrators (TPAs) play an important role in enrolment, networking, cashless services, grievance handling, and claim processing. Medical management focuses on appropriate treatment, disease control, and improving patient outcomes. Clinical audits ensure quality healthcare practices and adherence to treatment guidelines. Fraud prevention requires investigation, surveillance mechanisms, and strict action against intentional misconduct. Efficient underwriting, claims management, and provider partnerships enhance customer satisfaction and operational effectiveness. Proper documentation and compliance with policy terms are essential for fair claim settlement.
1. What is the primary purpose of clinical audit?
a) Increase hospital revenue
b) Systematic analysis of healthcare quality
c) Promote insurance sales
d) Reduce hospital admissions
2. Which department provides legal opinions on claim-related situations?
a) Finance Department
b) Underwriting Department
c) Legal Department
d) Marketing Department
3. Which regulation governs the licensing of TPAs in India?
a) IRDA Regulations, 1999
b) IRDA Regulations, 2000
c) IRDA Regulations, 2001
d) IRDA Regulations, 2010
4. What is the first step in claim processing?
a) Coding of claims
b) Registration of claim
c) Intimation of claim
d) Verification of documents
5. Medical management follows which health model?
a) Social model
b) Biomedical model
c) Economic model
d) Behavioral model
6. What mechanism should TPAs provide to policyholders?
a) Investment advice
b) Grievance representation
c) Tax planning
d) Legal counselling
7. Efficient insurance operations require:
a) Marketing and branding
b) Sound underwriting and efficient claims management
c) Large branch network
d) High premium rates
8. Investigation in claims may include verification of:
a) Pharmacy bills
b) Employer attendance
c) Hospital records
d) All of the above
9. Which characteristic is associated with fraud?
a) Accidental occurrence
b) Deliberate deception
c) Administrative delay
d) Clerical oversight
10. In cashless claims, pre-approval is generally obtained by:
a) The insured only
b) The regulator
c) Network hospital or TPA
d) Insurance agent
11. The cut-off point in TPA services refers to:
a) Claim repudiation date
b) Beginning or end of TPA servicing responsibility
c) Policy renewal date
d) Premium payment date
12. Controlling and monitoring a patient's illness during treatment is an example of:
a) Medical Management
b) Underwriting
c) Reinsurance
d) Product Pricing
13. Which of the following is a chronic ailment characteristic?
a) Detectable
b) Controllable
c) Treatable
d) Always avoidable
14. Which function forms the core of a TPA organization?
a) Finance
b) Networking
c) Claims
d) Marketing
15. Fraud committed by employees within an organization is called:
a) External Fraud
b) Soft Fraud
c) Internal Fraud
d) Opportunistic Fraud
16. Which activity is part of enrolment?
a) Adding members into TPA services
b) Settling claims
c) Conducting investigations
d) Negotiating tariffs
17. Which level of care involves super-specialized treatment facilities?
a) Primary Care
b) Secondary Care
c) Home Care
d) Tertiary Care
18. Registration of claim means:
a) Claim payment authorization
b) Entering the claim into the system and generating a reference number
c) Policy issuance
d) Fraud confirmation
19. What is the objective of fraud surveillance systems?
a) Increase claim payments
b) Reduce investigation efforts completely
c) Detect suspicious claim patterns efficiently
d) Replace TPAs
20. Which stakeholder helps process health insurance claims on behalf of insurers?
a) Broker
b) Agent
c) Third Party Administrator (TPA)
d) Surveyor
