UHC ETHICS & COMPLIANCE ACTUAL EXAM – QUESTIONS AND ANSWERS | VERIFIED AND WELL DETAILED
ANSWERS | PLUS RATIONALES | DOWNLOAD AND PASS | LATEST EXAM UPDATE 2026/2027
SECTION ONE: QUESTIONS 1 – 50
1. A health plan receives a request from a state regulator for access to member records as part of a routine
market conduct examination. The request does not include a subpoena or a member authorization. What is
the health plan’s most appropriate initial action?
A. Deny the request immediately due to the lack of member consent.
B. Provide the requested records only after redacting all member identifying information.
C. Fulfill the request after verifying the regulator’s authority and the scope of the examination.
D. Require the regulator to obtain a signed release from each member before releasing any information.
Correct Answer: C. Fulfill the request after verifying the regulator’s authority and the scope of the
examination.
Rationale: State regulators have statutory authority to conduct market conduct exams, and this authority typically
includes accessing protected health information without individual member consent. The most appropriate initial
action is to verify the regulator’s credentials and the scope of their request to ensure compliance with the specific
regulatory requirements and to document the disclosure appropriately. Options A and D are incorrect because they
,impose unnecessary barriers to a lawful regulatory request. Option B is incorrect because redacting information
would likely frustrate the purpose of the examination and is not required when the request is authorized by law.
2. A customer service representative receives a call from a member who is upset about a denied claim. The
member demands to know the name of the physician who reviewed the denial. Which of the following is the
representative’s best response?
A. Provide the name immediately to de-escalate the situation.
B. Inform the member that they have a right to request a written explanation of the denial but that the
reviewer’s name is confidential.
C. Escalate the call to a supervisor without providing any information to the member.
D. Transfer the member to the claims department and end the call.
Correct Answer: B. Inform the member that they have a right to request a written explanation of the denial
but that the reviewer’s name is confidential.
Rationale: While members have a right to information about their claims, the specific names of individual clinical
reviewers are generally considered proprietary or confidential business information and are not subject to
disclosure. The correct response acknowledges the member's concern, educates them on their right to a written
,explanation, and maintains confidentiality. Option A is a clear breach of policy. Option C is an escalation that may
be premature and does not address the member's query directly. Option D abdicates responsibility.
3. Which federal regulation requires health plans to provide a Notice of Privacy Practices to all members?
A. The Affordable Care Act (ACA)
B. The Health Insurance Portability and Accountability Act (HIPAA)
C. The Employee Retirement Income Security Act (ERISA)
D. The Consolidated Omnibus Budget Reconciliation Act (COBRA)
Correct Answer: B. The Health Insurance Portability and Accountability Act (HIPAA)
Rationale: The HIPAA Privacy Rule mandates that covered entities, including health plans, provide a Notice of
Privacy Practices (NPP) to individuals. The NPP describes how the entity uses and discloses protected health
information. The ACA, ERISA, and COBRA address other aspects of health coverage and employee benefits but are
not the primary drivers for the privacy notice requirement.
, 4. A claims processor notices a pattern of claims submitted by a single provider for a specific, expensive
procedure at a frequency significantly higher than peers in the same specialty. What is the claims processor’s
primary ethical and professional responsibility?
A. Ignore the pattern as it is not their role to question medical necessity.
B. Pay all claims that are coded correctly according to the CPT manual.
C. Report the pattern to their supervisor or the Special Investigations Unit (SIU) for further review.
D. Contact the provider directly to inquire about their practice patterns.
Correct Answer: C. Report the pattern to their supervisor or the Special Investigations Unit (SIU) for further
review.
Rationale: This situation describes a potential "red flag" for fraud, waste, or abuse. A claims processor has a duty
to report unusual or suspicious billing patterns to the appropriate internal department (SIU) to initiate a formal
investigation. Option A is incorrect because it ignores a potential compliance risk. Option B is incorrect because
paying claims without scrutiny, despite the suspicious pattern, could be a violation of the plan's fiduciary duties.
Option D is outside the processor's scope and could compromise an investigation.
ANSWERS | PLUS RATIONALES | DOWNLOAD AND PASS | LATEST EXAM UPDATE 2026/2027
SECTION ONE: QUESTIONS 1 – 50
1. A health plan receives a request from a state regulator for access to member records as part of a routine
market conduct examination. The request does not include a subpoena or a member authorization. What is
the health plan’s most appropriate initial action?
A. Deny the request immediately due to the lack of member consent.
B. Provide the requested records only after redacting all member identifying information.
C. Fulfill the request after verifying the regulator’s authority and the scope of the examination.
D. Require the regulator to obtain a signed release from each member before releasing any information.
Correct Answer: C. Fulfill the request after verifying the regulator’s authority and the scope of the
examination.
Rationale: State regulators have statutory authority to conduct market conduct exams, and this authority typically
includes accessing protected health information without individual member consent. The most appropriate initial
action is to verify the regulator’s credentials and the scope of their request to ensure compliance with the specific
regulatory requirements and to document the disclosure appropriately. Options A and D are incorrect because they
,impose unnecessary barriers to a lawful regulatory request. Option B is incorrect because redacting information
would likely frustrate the purpose of the examination and is not required when the request is authorized by law.
2. A customer service representative receives a call from a member who is upset about a denied claim. The
member demands to know the name of the physician who reviewed the denial. Which of the following is the
representative’s best response?
A. Provide the name immediately to de-escalate the situation.
B. Inform the member that they have a right to request a written explanation of the denial but that the
reviewer’s name is confidential.
C. Escalate the call to a supervisor without providing any information to the member.
D. Transfer the member to the claims department and end the call.
Correct Answer: B. Inform the member that they have a right to request a written explanation of the denial
but that the reviewer’s name is confidential.
Rationale: While members have a right to information about their claims, the specific names of individual clinical
reviewers are generally considered proprietary or confidential business information and are not subject to
disclosure. The correct response acknowledges the member's concern, educates them on their right to a written
,explanation, and maintains confidentiality. Option A is a clear breach of policy. Option C is an escalation that may
be premature and does not address the member's query directly. Option D abdicates responsibility.
3. Which federal regulation requires health plans to provide a Notice of Privacy Practices to all members?
A. The Affordable Care Act (ACA)
B. The Health Insurance Portability and Accountability Act (HIPAA)
C. The Employee Retirement Income Security Act (ERISA)
D. The Consolidated Omnibus Budget Reconciliation Act (COBRA)
Correct Answer: B. The Health Insurance Portability and Accountability Act (HIPAA)
Rationale: The HIPAA Privacy Rule mandates that covered entities, including health plans, provide a Notice of
Privacy Practices (NPP) to individuals. The NPP describes how the entity uses and discloses protected health
information. The ACA, ERISA, and COBRA address other aspects of health coverage and employee benefits but are
not the primary drivers for the privacy notice requirement.
, 4. A claims processor notices a pattern of claims submitted by a single provider for a specific, expensive
procedure at a frequency significantly higher than peers in the same specialty. What is the claims processor’s
primary ethical and professional responsibility?
A. Ignore the pattern as it is not their role to question medical necessity.
B. Pay all claims that are coded correctly according to the CPT manual.
C. Report the pattern to their supervisor or the Special Investigations Unit (SIU) for further review.
D. Contact the provider directly to inquire about their practice patterns.
Correct Answer: C. Report the pattern to their supervisor or the Special Investigations Unit (SIU) for further
review.
Rationale: This situation describes a potential "red flag" for fraud, waste, or abuse. A claims processor has a duty
to report unusual or suspicious billing patterns to the appropriate internal department (SIU) to initiate a formal
investigation. Option A is incorrect because it ignores a potential compliance risk. Option B is incorrect because
paying claims without scrutiny, despite the suspicious pattern, could be a violation of the plan's fiduciary duties.
Option D is outside the processor's scope and could compromise an investigation.
