IC36 Mock Test Sample 20
Health insurance claim management emphasizes accurate adjudication, fraud prevention, policy compliance, and efficient coordination among insurers, TPAs, providers, and policyholders. TPAs facilitate quality healthcare access at reasonable costs through standardized operating procedures, hospital relationship management, and information technology support. Clinical audits improve treatment quality, while claim scrutiny ensures admissibility and prevents impersonation, non-disclosure, and document tampering. Understanding medical coding, treatment protocols, and policy conditions is essential for effective claims handling. The healthcare ecosystem focuses on balancing patient wellness, cost containment, provider accountability, and timely settlement while maintaining ethical and regulatory standards.
Q1. When does a claim amount become inflated under a policy?
a) Claiming inadmissible expenses
b) Claiming personal pocket expenses
c) Treating the sum insured as an entitlement
d) Filing claims only for admissible expenses
Q2. TPAs aim to provide access to quality healthcare at ________ cost.
a) Optimum
b) Fair
c) Reasonable
d) Best
Q3. Which of the following represents a typical fraud pattern?
a) Concealing pre-existing diseases
b) Fabricating claims through non-existent hospitals
c) Providing promised treatments
d) Maintaining accurate records
Q4. Which word is opposite in meaning to "adjudication"?
a) Conclusion
b) Judgment
c) Verdict
d) Indecision
Q5. Mahesh's policy allows room rent up to 1% of the sum insured. If the sum insured is ₹1,00,000, the eligible room rent per day would be:
a) ₹800
b) ₹1,000
c) ₹1,200
d) ₹1,500
Q6. Under which approach is health viewed as maintaining wellness and preventing complications?
a) Clinical Management
b) Medical Management
c) Claims Management
d) Case Management
Q7. Effective hospital relationship management by TPAs includes:
a) Understanding hospital protocols
b) Reviewing claim settlement timelines
c) Prioritizing claims based on disease severity
d) Ignoring internal performance measures
Q8. Clinical audit primarily benefits which stakeholder initially?
a) Payers
b) Providers
c) Insurers
d) Buyers
Q9. Which statement about blood pressure is incorrect?
a) It reflects pressure exerted by circulating blood
b) It is expressed as systolic over diastolic pressure
c) Diastolic pressure is the upper reading
d) It is important in circulatory system assessment
Q10. Which procedure is specific to the urinary system?
a) Dialysis
b) Renal Transplant
c) Urethral Catheterization
d) Prostatectomy
Q11. Insurers may provide _________ to TPAs for standardized claim processing.
a) Standard Operating Procedure
b) Standard Operating Protocol
c) Standard Procedure Protocol
d) Standard Operative Procedure
Q12. Which codes are never used as the primary diagnosis code?
a) ICD-10 Codes
b) ICD-9 Codes
c) V-Codes
d) E-Codes
Q13. Matching the hospitalized person with policy details helps prevent:
a) Hospitalization
b) Confusion
c) Mistakes
d) Impersonation
Q14. The Information Technology stream of a TPA mainly supports:
a) Recruitment activities
b) Transaction processing and communication management
c) Investigation of all claims
d) Premium collection only
Q15. In the health insurance market, treatment decisions are largely controlled by:
a) Policyholders
b) Regulators
c) Providers
d) Payers
Q16. Which of the following is important for claim compliance?
a) Timely claim intimation
b) Submission of required documents
c) Avoidance of document tampering
d) Proper disclosure of facts
Q17. Which activity helps ensure accurate claim adjudication?
a) Random settlements
b) Careful scrutiny of submitted documents
c) Ignoring medical records
d) Delaying claim registration
Q18. Which stakeholder generally bears the treatment cost in health insurance?
a) Provider
b) Payer
c) Regulator
d) Agent
Q19. Standard Operating Procedures are designed to ensure:
a) Uniformity in claim processing
b) Increased premium rates
c) Reduction in policy issuance
d) Elimination of hospital networks
Q20. Which practice should be avoided to maintain claim integrity?
a) Prompt claim notification
b) Honest disclosure of facts
c) Tampering with documents
d) Submitting supporting records
