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Mar 21, 2025 5:40 PM

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Compliance allegations process

Spark is here to help!

We are here to help you address the complaint, support you with your response if needed, coach as needed, identify root causes to help you prevent future allegations.

Communication between you, your immediate upline and Spark Compliance is key!  We can only help if you keep us in the loop.

1. Client makes an allegation - through carrier, Medicare/CMS or DOI
2. The carrier begins their investigation by requesting information from the agent via an email to the agent and Spark OR emails Spark directly. *Note - You as an agent agree to cooperate and respond to any inquiries in your Carrier agreements.
3. Spark Compliance sends an email to the agent and immediate upline (or compliance person identified at agency): *Note - The emails from Spark may come through our secure email, Zivver.
1. Requesting an agent statement and/or any recordings, SOA, copy of application with a due date.
2. If the agent responds directly to the carrier, Spark requests the agent cc in Spark Compliance on all communications about the allegation.
3. Spark returns agent statement/response to the carrier
4. Carrier conducts an investigation and determines whether the allegation is founded, inconclusive, or unfounded
5. Depending on allegation findings, frequency and number of agent allegations, the carrier will take corrective action. It can be any of the following or a combination.
1. Read and/or complete a training module and send completed action via email
2. Sign an attestation that they understand and will comply with rules in the future
3. Coaching may be required - verbal or written
4. A warning may be issued - written or verbal
5. Agent termination - if allegations continue
6. The agent must complete any corrective action by the due date given by the carrier.

Receiving an Allegation

Please follow the specific instructions from the carrier. In general, this is a good guideline for what you should submit to the carrier (see Humana, Aetna examples) You may copy the template, complete it, and submit it to the carrier.

Note allegations by beneficiaries are taken seriously by the carrier. Carriers typically follow this process: (1) an allegation is made by a beneficiary directly or by a carrier support representative (2) the carrier investigates by requesting information from the agent (3) the agent responds with supporting evidence (4) the carrier determines whether the allegation is founded (5) if founded, the carrier will take corrective action, which is typically verbal or written coaching for the first founded allegation. Carriers may choose to terminate agent appointments if allegations continue to arise.