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Appeals

All subscribers have the right to appeal any decision about benefits offered through the Public Employees Benefits Board (PEBB) Program after a specific denial or decision.

An appeal is more than a complaint or criticism. An appeal is made in response to a denial or decision about your account. In making an appeal, you must explain why you think the denial or decision was wrong.

For a description of the appeals rules, see Washington Administrative Code 182-16.

Does this process include appealing a decision made by my health plan or other insurance carrier?

No. Each health plan or insurance carrier (such as medical, dental, life, long-term care, long-term disability, auto/home, flexible spending account or Dependent Care Assistance Program) has a process for appealing decisions. Follow the appeal rights and procedures in the plan’s or insurance carrier’s member materials. If you have exhausted your plan's or insurance carrier's appeals process and still disagree, you may have other options.

What types of issues can I appeal to PEBB?

PEBB makes eligibility and enrollment decisions about:

• Student dependents
• Adult dependents
• Extended dependents
• Dependents with disabilities
• Retirees
• Survivors
• COBRA or Continuation of Coverage members
• Leave Without Pay subscribers

Eligibility decisions address whether someone qualifies for insurance coverage, as described in PEBB rules and policies.

Enrollment decisions address the application for PEBB benefits, as described in PEBB rules and policies, such as submitting proper documentation and meeting enrollment deadlines.

The PEBB Program also makes decisions related to premium payments.

What is the appeal process?

State, higher education and K-12, and employer group employees follow this process:

Retiree, Survivor, COBRA, and Leave Without Pay subscribers follow this process:

If you disagree with a decision about eligibility or enrollment that affects you or a dependent, submit a request for review with your employing agency within 30 days of your agency’s denial notice. For guidance on what to include, see WAC 182-16-040 or use PEBB’s Request for Review form (269.5 KB). Your employing agency will review its initial decision within 30 days of receiving your request for review. Your employing agency will give you a written Employer Decision Notice. If you disagree with your employing agency’s decision, you can appeal it by submitting a notice of appeal to the PEBB Appeals Committee. The PEBB Appeals Committee must receive your Notice of Appeal within 30 days of the date on the employing agency’s Employer Decision Notice. Submit your Notice of Appeal to PEBB online. (You will be asked to register to fill out the form on our secure server or to log in if already registered.) or print out and mail your Notice of Appeal (267.7 KB) to: Health Care Authority PEBB Appeals P.O. Box 42699 Olympia, WA 98504-2699 The PEBB appeals committee will make its decision within 30 days of receiving your notice of appeal. The appeals manager will send you a letter informing you of the committee’s decision. If you disagree with the decision of the PEBB Appeals Committee, you may request an administrative hearing. See Administrative hearings below.

If you disagree with an eligibility or enrollment decision made by the PEBB Program, file a notice of appeal with the PEBB Appeals Committee. PEBB must receive your notice of appeal within 60 days of the date of the PEBB Program’s initial decision. Include supporting documentation. For guidance on what to include, see WAC 182-16-040. Submit your Notice of Appeal to PEBB online. (You will be asked to register to fill out the form on our secure server or to log in if already registered.) or print out and mail your Notice of Appeal (267.7 KB) to: Health Care Authority PEBB Appeals P.O. Box 42699 Olympia, WA 98504-2699 The PEBB Appeals Committee will make a decision within 30 days of receiving your notice of appeal. The appeals manager will send you a letter informing you of the committee’s decision. If you disagree with the decision of the PEBB Appeals Committee, you may request an administrative hearing. See Administrative hearings below.

Administrative Hearings

If you are not satisfied with the decision of the PEBB Appeals Committee, you may request an administrative hearing.

The request must be made in writing to the PEBB appeals manager. The PEBB appeals manager must receive your written request for a hearing within 30 days of the date of the written decision of the PEBB Appeals Committee.

The HCA will give you at least 20 days notice of the time and place of the hearing.

The administrator or his or her designee will make a final decision within 90 days after the hearing record is closed. A copy of that decision, including the reasons for the decision, will be sent to everyone involved with the appeal.