Bookmark & ShareAny member may appeal a decision about benefits offered through the Public Employees Benefits Board (PEBB) Program after a specific denial or decision.
The appeals rules are in Washington Administrative Code 182-16.
Does This Process Let Me Appeal a Decision By My Health Plan or Other Insurance Carrier?
No. To appeal a decision or action by a health plan or insurance carrier about a claim or benefit (such as a dispute about a course of treatment or billing), contact the health plan or insurance carrier to ask how to appeal. If you have followed your plan's or carrier's appeals process and still disagree with the outcome, you may have other options.
What Types of Issues Can I Appeal?
You can appeal decisions or actions about eligibility, enrollment, and premium payments.
- Eligibility decisions address whether someone qualifies for insurance coverage, as described in PEBB rules and policies.
- Enrollment decisions address the application for PEBB benefits, such as submitting proper documentation and meeting enrollment deadlines, as described in PEBB rules and policies.
- Premium payments address what and when you pay for your monthly premiums.
What is the Appeal Process?
Submit the Request for Review/Notice of Appeal form as described below.
If you are: |
You must: |
|---|---|
| A state agency or higher-education employee or the dependent of one, seeking a review of a decision or action by your employer or the Public Employees Benefits Board (PEBB) Program concerning eligibility, enrollment for benefits, or premium payments | Submit the Request for Review/Notice of Appeal form to your employer or the PEBB Program (whichever made the decision you are appealing) no later than 30 days from the decision or action you are appealing. |
| A retiree, survivor, COBRA member, Leave Without Pay member, PEBB Extension of Coverage member, or the dependent of one, seeking a review of a decision or action by the PEBB Program | Submit the Request for Review/Notice of Appeal form to the PEBB Program no later than 60 days from the PEBB Program's decision or action. |
| An employer group or K-12 school district employee or the dependent of one, with an appeal concerning eligibility or enrollment decisions regarding life or long-term disability insurance | Submit the Request for Review/Notice of Appeal form to the PEBB Program no later than 30 days from the decision or action you are appealing. |
| An employer group or K-12 school district employee or the dependent of one, with an appeal concerning eligibility or enrollment for health benefits | Contact your employer to request information on how to appeal their decision or action. |
| Any PEBB enrollee seeking a review of a decision or action by a health plan or insurance carrier about a claim or benefit (such as a dispute about a course of treatment or billing) | Contact the health plan or insurance carrier to request information on how to appeal their decision or action. |
Administrative Hearings
(Available only to employees of state agencies, higher-education institutions and community and technical colleges.) If you are not satisfied with the decision of the PEBB Appeals Committee, you may request an administrative hearing.
You must submit your request in writing to the PEBB appeals manager. The PEBB appeals manager must receive your written request for a hearing no later than 30 days from the date of the PEBB Appeals Committee's decision.
