IC36 Mock Test Sample 18
Health insurance claims management focuses on timely claim intimation, creation of reserves, proper documentation, medical management, fraud control, and customer service. TPAs facilitate cashless hospitalization, maintain provider networks, operate call centers, and support data analysis and claims processing. Medical management aims to restore health, improve wellness, and contain costs through interventions and expert guidance. Fraud may involve customers, providers, TPAs, agents, or employees and requires vigilant monitoring. Information technology strengthens TPA operations through workflow automation, validation systems, reporting, and customer interfaces. Effective provider management enhances policyholder satisfaction and improves claim settlement efficiency.
1. Claim intimation is considered the first instance of:
a) Contract
b) Contact
c) Judgment
d) Investigation
2. The reserve created immediately after claim intimation is generally based on:
a) Policy premium
b) Sum insured
c) Historic average claim size
d) Customer age
3. The primary objective of a hospital network developed by TPAs is to provide:
a) Tax benefits
b) Cashless access and hassle-free services
c) Investment opportunities
d) Higher premiums
4. Which stakeholder may potentially be involved in insurance fraud?
a) Providers
b) Customers
c) Agents
d) All of the above
5. Information Technology in TPA operations helps in:
a) Workflow automation
b) Validation and rule engines
c) Trend analysis through MIS
d) All of the above
6. Medical management primarily aims at:
a) Reviewing fraudulent claims
b) Restoring physical well-being
c) Increasing premium income
d) Recruiting healthcare staff
7. Plasma transfusion is commonly used to:
a) Improve eyesight
b) Replace impaired clotting factors
c) Reduce fever
d) Enhance digestion
8. Under a health insurance policy, which event should generally occur within the policy period?
a) Policy proposal
b) Admission to hospital
c) Premium revision
d) Claim closure
9. Which of the following is an example of abuse by an insurer?
a) Timely claim payment
b) Denying a valid claim without evidence
c) Cashless settlement
d) Policy renewal
10. A break-up of unclear bills is sought to establish the:
a) Profitability of the claim
b) Admissibility of the claim
c) Customer loyalty
d) Hospital ranking
11. Expert opinion integrated into claim systems can enhance:
a) Office administration
b) Medical management and cost containment
c) Sales performance
d) Premium collection
12. Cost control structures in health insurance include:
a) Product design
b) Claims management
c) Provider management
d) All of the above
13. Services provided by TPAs include:
a) Cashless facilitation
b) Call center support
c) Hospital networking
d) All of the above
14. Senior citizen healthcare offerings may include:
a) Regular health check-ups
b) Nursing assistance
c) Arthritis care programs
d) All of the above
15. Prognostic care systems contribute mainly toward:
a) Fraud investigation
b) Medical management improvement
c) Investment planning
d) Reinsurance decisions
16. Employees giving undue favor in claims settlement may be involved in:
a) Customer service
b) Fraud benefiting customers
c) Medical audit
d) Underwriting review
17. A TPA should understand policy terms thoroughly to:
a) Avoid processing errors
b) Bridge interpretation gaps
c) Ensure accurate claim implementation
d) All of the above
18. External reports generated by TPAs may include:
a) Daily claims reports
b) Cashless authorization reports
c) Outstanding claims reports
d) All of the above
19. A reimbursement claim generally arises when:
a) Cashless authorization is unavailable during emergency admission
b) Premium remains unpaid
c) The policy has lapsed
d) The hospital refuses treatment
20. Which statement best describes medical management?
a) Focuses only on claim settlement
b) Supports cost containment and health restoration
c) Deals exclusively with fraud detection
d) Operates independently of healthcare providers
