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Appeals

Any 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 find out 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.

How Do I Submit an Appeal?

Submit the Request for Review/Notice of Appeal form as described below.

If you are...	...and your appeal concerns:	You must:
A state agency or higher-education employee (or the dependent of one)...	A decision or action by your employer or the Public Employees Benefits Board (PEBB) Program about eligibility for benefits, enrollment, 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). The employer or PEBB Program must receive the form no later than 30 days from the date of the denial notice or decision or action you are appealing.
A retiree A surviving spouse A member through: COBRA, Leave Without Pay, or PEBB Extension of Coverage Or the dependent of one of the above...	A decision or action by the PEBB Program about eligibility for benefits, enrollment, or premium payments.	Submit the Request for Review/Notice of Appeal form to the PEBB Program. The PEBB Program must receive the form no later than 60 days from the date of the denial notice or its decision or action.
An employee (or the dependent of one) of: a county a municipality a political subdivision a tribal government a school district an educational service district the Washington Health Benefit Exchange an employee organization representing state civil service employees	A decision or action by your employer about eligibility for benefits or enrollment. A decision by the PEBB Program about eligibility, enrollment, or premium payment. A decision or action by your employer or the PEBB Program about life or long-term disability insurance.	Contact your employer to request information on how to appeal its decision or action. Submit the Request for Review/Notice of Appeal form to the PEBB Program. The PEBB Program must receive the form no later than 30 days from the date of the denial notice or your employer’s decision or action.
Seeking a review of a decision or action by a health plan, insurance carrier, or the FSA and DCAP administrator…	A claim or benefit (for example, a dispute about a course of treatment or billing).	Contact the plan, insurance carrier or benefit administrator, to request information on how to appeal.

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.