IC36 Mock Test Sample 5
IC36 Health Insurance Claims Management involves evaluating claim admissibility, calculating the payable amount, and applying policy conditions such as co-payment, deductibles, and coverage limits. TPAs play a crucial role in cashless claim processing by maintaining policy records, issuing pre-authorizations, and coordinating with hospitals. Medical coding systems such as CPT and ICD facilitate standardized classification of procedures, diseases, and mortality data. Understanding healthcare concepts, diagnostic investigations, hospital accreditation standards, and payment mechanisms like bank uploads improves claims efficiency. Proper scrutiny of claim documents ensures accurate settlements while maintaining transparency and customer satisfaction.
1. Once a claim is found admissible, the next step is to:
a) Verify policy issuance
b) Arrive at the final claim payable
c) Request policy renewal
d) Conduct underwriting
2. During cashless treatment, patients may be required to make deposits towards:
a) Non-medical expenses
b) Co-payment amounts
c) Deductibles under the policy
d) All of the above
3. CPT codes are primarily used as:
a) Mortality codes
b) Procedural codes
c) Pharmacy codes
d) Diagnostic codes
4. Which statement regarding tissues is incorrect?
a) Tissues are groups of similar cells
b) Tissues perform specific functions
c) A group of tissues forms a cell
d) Cells combine to form tissues
5. The flat percentage of an assessed claim paid by the insured is called:
a) Final settlement
b) Co-payment
c) Approved amount
d) Deduction charge
6. Efficient functioning of TPAs requires:
a) Availability of policy details
b) Access to member information
c) Clear pre-authorization procedures
d) All of the above
7. Which coding system is used for mortality data from death certificates?
a) ICD-9-CM
b) ICD-10
c) V-Codes
d) CPT Codes
8. Endocrinology deals with diseases related to:
a) Blood
b) Hormones
c) Skin
d) Bones
9. Medical coding is currently used to classify diseases and:
a) Financial records
b) Procedural data
c) Premium calculations
d) Marketing information
10. Expenses incurred for curing illness mainly include:
a) Administrative costs
b) Treatment-related costs
c) Transportation expenses
d) Accommodation charges only
11. ICD-10 mortality coding has been implemented in many countries to improve:
a) Premium collection
b) Standardization of health information
c) Policy sales
d) Claim repudiation
12. While arriving at the final claim amount, insurers generally:
a) Deduct non-payable items
b) Apply policy limits
c) Calculate co-payment
d) All of the above
13. TPA claim processing services usually include:
a) Registering claim intimations
b) Processing claim documents
c) Recommending approvals
d) All of the above
14. Which of the following is NOT commonly considered an investigation test?
a) Blood Sugar Test
b) Anthropometry
c) X-Ray
d) Ultrasonography (USG)
15. Which statement regarding the bank upload system is incorrect?
a) Claim payment data is uploaded electronically
b) It enables efficient claim settlements
c) Banks can facilitate direct fund transfers
d) The system slows down claim processing
16. Yellow discoloration of the skin and eyes due to contaminated water may indicate:
a) Hepatitis B
b) Hepatitis C
c) Hepatitis A or Hepatitis E
d) Malaria
17. After the claim amount is finalized, the approved amount is usually forwarded to the:
a) Sales Department
b) Finance Department
c) Marketing Department
d) Underwriting Department
18. NABH accreditation standards generally cover all except:
a) Patient care processes
b) Infection control practices
c) Access and continuity of care
d) Insurance premium rating methods
19. Which of the following is NOT typically categorized under tertiary care services?
a) Intensive Care Unit (ICU)
b) Advanced imaging facilities
c) Operating theatres
d) General outpatient registration desk
20. During claim scrutiny, documents commonly reviewed include:
a) Investigation reports
b) Discharge summaries
c) Payment receipts
d) All of the above
