Health Insurance Practice Exam
Health Insurance Practice Exam
About Health Insurance Exam
The Health Insurance Exam is crafted to evaluate a candidate’s understanding of the health insurance industry, including policy structures, underwriting, claims processing, and regulatory compliance. It covers individual and group plans, private and government-sponsored schemes, provider networks, and ethical practices. This exam is ideal for professionals working in insurance, healthcare administration, or financial services, aiming to build or validate expertise in health coverage systems.
Who should take the Exam?
This exam is ideal for:
- Insurance agents, brokers, and advisors involved in selling or managing health policies
- Healthcare administrators and billing professionals
- Claims processors, underwriters, and insurance operations staff
- Finance and HR professionals handling employee health benefits
- Compliance officers and legal personnel in insurance companies
Skills Required
- Understanding of different types of health insurance products
- Knowledge of health-related underwriting and risk assessment
- Ability to navigate claims processes and customer queries
- Awareness of regulatory frameworks and compliance standards
- Communication skills for client and provider interactions
Knowledge Gained
- Comprehensive understanding of private and public health insurance
- Insight into policy structures, premiums, co-payments, and deductibles
- Clarity on pre-authorizations, provider networks, and claims adjudication
- Familiarity with health insurance laws, including HIPAA and IRDAI regulations
- Ability to advise clients and stakeholders on optimal coverage options
Course Outline
The Health Insurance Exam covers the following topics -
Domain 1 – Introduction to Health Insurance
- Basic concepts, importance, and stakeholders in health insurance
- Differences between health, life, and general insurance
- Market trends and industry scope
Domain 2 – Types of Health Insurance Plans
- Individual vs. group insurance plans
- Government schemes (Medicare, Medicaid, Ayushman Bharat)
- Private and employer-sponsored plans
Domain 3 – Policy Terms and Coverage
- Premiums, deductibles, coinsurance, co-pays
- Inclusions, exclusions, and waiting periods
- Renewability, portability, and riders
Domain 4 – Underwriting and Risk Assessment
- Medical underwriting process and criteria
- Pre-existing conditions and exclusions
- Risk classification and pricing models
Domain 5 – Claims Process and Adjudication
- Pre-authorization, cashless vs. reimbursement process
- Role of third-party administrators (TPAs)
- Grievance redressal and claim denial appeals
Domain 6 – Regulatory Framework
- IRDAI rules and guidelines
- HIPAA compliance and data confidentiality
- Consumer protection and insurance ombudsman
Domain 7 – Provider Network and Hospitalization
- In-network vs. out-of-network care
- Pre-authorization and discharge documentation
- Coverage for daycare, maternity, and preventive services
Domain 8 – Health Insurance for Special Populations
- Insurance for senior citizens and chronic patients
- Family floater and maternity plans
- Coverage for mental health and wellness services
Domain 9 – Sales, Marketing, and Distribution
- Role of agents, brokers, and digital platforms
- Policy illustration, benefit explanation, and client counseling
- Ethical selling and disclosure norms
Domain 10 – Health Insurance Fraud and Audit
- Common fraud schemes and red flags
- Internal audit and fraud detection mechanisms
- Legal consequences and corrective actions
