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.
What 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.
Does this process let me appeal a decision made by a plan?
No. To appeal a decision or action made by a plan about a claim or benefit (like a course of treatment or billing), contact the plan
. If you have already followed the plan's appeals process and still disagree with the outcome, you may have other options
How do I submit an appeal?
State agency employee,
dependent of one of the above
|Your employer or the Public Employees Benefits Board (PEBB) Program about eligibility for benefits, enrollment, or premium payments
||Submit a Request for Review/Notice of Appeal form to your employer or the PEBB Program (whichever made the decision you are appealing)
||Your employer or the 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.|
COBRA, Leave Without Pay, or PEBB Extension of Coverage member,
dependent of one of the above
|The PEBB Program about eligibility for benefits, enrollment, or premium payments
||Submit a 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 dependent 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) Your employer about eligibility for benefits or enrollment,
B) The PEBB Program about eligibility, enrollment, or premium payment,
C) 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, or 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. |
If you want to appeal a decision or action made by a health plan, you must contact the plan for help.
(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.