Missouri Health Insurance Compliance
Analyst Exam Practice Questions And
Correct Answers (Verified Answers) Plus
Rationale 2026 Q&A| Instant Download
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1. A Missouri Health Insurance Compliance Analyst is reviewing a claim
submission and notices that the diagnosis code does not support the
procedure billed. Which compliance principle is most directly violated?
A. Medical necessity
B. Timely filing
C. Coordination of benefits
D. Subrogation
Answer: A. Medical necessity
Rationale: Medical necessity requires that services billed must be
supported by appropriate diagnosis codes demonstrating the need
for the procedure; mismatch indicates noncompliance.
,2. Which federal law primarily governs the protection of patient health
information in health insurance transactions?
A. ERISA
B. HIPAA
C. COBRA
D. HITECH Act
Answer: B. HIPAA
Rationale: HIPAA establishes national standards for protecting
sensitive patient health information and governs privacy and security
compliance.
3. Under HIPAA, what is the maximum civil penalty for willful neglect not
corrected within a required time period per violation category per
year?
A. $10,000
B. $50,000
C. $100,000
D. $1.5 million
Answer: D. $1.5 million
Rationale: HIPAA establishes tiered penalties, with willful neglect not
corrected reaching up to $1.5 million annually per violation category.
4. A compliance analyst discovers a pattern of upcoding. What is the
most appropriate first action?
A. Report immediately to law enforcement
, B. Conduct an internal audit investigation
C. Terminate involved staff
D. Refund all claims immediately
Answer: B. Conduct an internal audit investigation
Rationale: Internal investigation verifies the issue, scope, and intent
before escalation or corrective actions.
5. Which act requires health plans to provide continuation coverage after
qualifying events such as job loss?
A. HIPAA
B. ERISA
C. COBRA
D. ACA
Answer: C. COBRA
Rationale: COBRA mandates continuation of health coverage for
eligible individuals after certain qualifying events.
6. What is the primary purpose of the Affordable Care Act (ACA)?
A. Eliminate all private insurance
B. Expand healthcare coverage and reduce costs
C. Replace Medicare
D. Limit Medicaid eligibility
Answer: B. Expand healthcare coverage and reduce costs
Rationale: The ACA aims to increase access to insurance coverage
and control healthcare costs.
, 7. Which coding system is used for reporting diagnoses in health
insurance claims?
A. CPT
B. HCPCS
C. ICD-10-CM
D. DRG
Answer: C. ICD-10-CM
Rationale: ICD-10-CM codes classify diagnoses and are required for
claims submission.
8. A claim denied due to lack of prior authorization falls under which
compliance issue?
A. Eligibility verification
B. Authorization requirement
C. Billing accuracy
D. Coding compliance
Answer: B. Authorization requirement
Rationale: Many services require prior authorization; failure to
obtain it leads to denial.
9. Which federal agency enforces HIPAA compliance?
A. CMS
B. HHS Office for Civil Rights
C. FDA
D. DOJ
Analyst Exam Practice Questions And
Correct Answers (Verified Answers) Plus
Rationale 2026 Q&A| Instant Download
1. A Missouri Health Insurance Compliance Analyst is reviewing a claim
submission and notices that the diagnosis code does not support the
procedure billed. Which compliance principle is most directly violated?
A. Medical necessity
B. Timely filing
C. Coordination of benefits
D. Subrogation
Answer: A. Medical necessity
Rationale: Medical necessity requires that services billed must be
supported by appropriate diagnosis codes demonstrating the need
for the procedure; mismatch indicates noncompliance.
,2. Which federal law primarily governs the protection of patient health
information in health insurance transactions?
A. ERISA
B. HIPAA
C. COBRA
D. HITECH Act
Answer: B. HIPAA
Rationale: HIPAA establishes national standards for protecting
sensitive patient health information and governs privacy and security
compliance.
3. Under HIPAA, what is the maximum civil penalty for willful neglect not
corrected within a required time period per violation category per
year?
A. $10,000
B. $50,000
C. $100,000
D. $1.5 million
Answer: D. $1.5 million
Rationale: HIPAA establishes tiered penalties, with willful neglect not
corrected reaching up to $1.5 million annually per violation category.
4. A compliance analyst discovers a pattern of upcoding. What is the
most appropriate first action?
A. Report immediately to law enforcement
, B. Conduct an internal audit investigation
C. Terminate involved staff
D. Refund all claims immediately
Answer: B. Conduct an internal audit investigation
Rationale: Internal investigation verifies the issue, scope, and intent
before escalation or corrective actions.
5. Which act requires health plans to provide continuation coverage after
qualifying events such as job loss?
A. HIPAA
B. ERISA
C. COBRA
D. ACA
Answer: C. COBRA
Rationale: COBRA mandates continuation of health coverage for
eligible individuals after certain qualifying events.
6. What is the primary purpose of the Affordable Care Act (ACA)?
A. Eliminate all private insurance
B. Expand healthcare coverage and reduce costs
C. Replace Medicare
D. Limit Medicaid eligibility
Answer: B. Expand healthcare coverage and reduce costs
Rationale: The ACA aims to increase access to insurance coverage
and control healthcare costs.
, 7. Which coding system is used for reporting diagnoses in health
insurance claims?
A. CPT
B. HCPCS
C. ICD-10-CM
D. DRG
Answer: C. ICD-10-CM
Rationale: ICD-10-CM codes classify diagnoses and are required for
claims submission.
8. A claim denied due to lack of prior authorization falls under which
compliance issue?
A. Eligibility verification
B. Authorization requirement
C. Billing accuracy
D. Coding compliance
Answer: B. Authorization requirement
Rationale: Many services require prior authorization; failure to
obtain it leads to denial.
9. Which federal agency enforces HIPAA compliance?
A. CMS
B. HHS Office for Civil Rights
C. FDA
D. DOJ
