IC36 Mock Test Sample 7
IC36 Health Insurance Claims Management focuses on claim admissibility, fraud detection, provider networks, and quality healthcare delivery. Claims may be denied due to exclusions, policy conditions, or incomplete documentation. Health insurers establish provider networks to streamline treatment and improve customer experience. Provider profiling uses indicators such as readmission rates, complication rates, mortality rates, and patient satisfaction to assess quality of care. Medical terminology, ICD coding, and understanding of co-morbidities support accurate claim adjudication. Effective claims management requires timely processing, investigation of suspicious claims, adherence to statutory norms, and maintaining high standards of customer service.
1. A health insurance claim may be denied due to:
a) Pre-existing conditions excluded under the policy
b) Illness resulting from alcohol or drug abuse
c) Non-compliance with hospitalization requirements
d) All of the above
2. Which of the following is considered a part of secondary care?
a) General Practitioner
b) Internist
c) Paramedic
d) Community Health Worker
3. ________ help define the clinical actions and treatments received by a patient.
a) Medical Codes
b) Interventions
c) Investigation Reports
d) Claims Reports
4. The medical term for piles is:
a) Atherosclerosis
b) Neuropathy
c) Haemorrhoids
d) Nephropathy
5. A policyholder can seek grievance redressal from:
a) Insurance Ombudsman
b) Consumer Forums
c) Legal Authorities
d) All of the above
6. To streamline healthcare services, insurers create a:
a) Network of Providers
b) Network of Investors
c) Network of Agents
d) Network of Auditors
7. Provider profiling uses which of the following indicators?
a) Readmission rates
b) Patient satisfaction measures
c) Complication rates
d) All of the above
8. Coughing up blood due to respiratory conditions is known as:
a) Cyanosis
b) Bronchitis
c) Haemoptysis
d) Choking
9. Healthcare providers may include:
a) Diagnostic services
b) Nursing homes
c) Ambulance services
d) All of the above
10. The ICD code category for unspecified stroke conditions is generally represented by:
a) I-Series codes
b) J-Series codes
c) D-Series codes
d) E-Series codes
11. Organs in the human body are composed of two or more types of:
a) Cells
b) Tissues
c) Nerves
d) Muscles
12. If fabricated bills are submitted with a claim, the insurer may:
a) Pay the entire claim amount
b) Ignore the discrepancy
c) Seek clarification and investigate the matter
d) Increase the sum insured
13. When fraud is suspected in a claim, it is usually referred for:
a) Settlement
b) Investigation
c) Arbitration
d) Reimbursement
14. Healthcare entities are expected to comply with statutory requirements such as:
a) Fire safety norms
b) Relevant healthcare legislation
c) Registration requirements
d) All of the above
15. The occurrence of hypertension along with a heart attack is an example of:
a) Primary Diagnosis
b) Essential Hypertension
c) Co-morbidity
d) Acute Syndrome
16. A decubitus ulcer is commonly known as:
a) Hair follicle infection
b) Bed sore
c) Skin allergy
d) Fungal infection
17. Delay in claim submission may be considered if:
a) No explanation is provided
b) The delay is supported by an acceptable reason
c) The policy has expired
d) The insured changes hospitals
18. Which organ loses its importance after a particular stage of life?
a) Liver
b) Brain
c) Pancreas
d) Uterus
19. Claims departments are under constant pressure to ensure accurate ________ of claims.
a) Marketing
b) Promotion
c) Adjudication
d) Underwriting
20. An approach that aims to control healthcare costs while ensuring quality is called:
a) Managed Care
b) Fee-for-Service
c) Customary Care
d) Open Access Care
