Employee and retiree benefits

File an appeal: PEBB

Find out how you can appeal a decision or denial by your employer or the Public Employees Benefits Board (PEBB) Program.

Who can appeal?

If you are a subscriber, dependent, or applicant for PEBB Program benefits, you may be able to file an appeal of a decision made by your employer or the PEBB Program. The rules for filing an appeal are in WAC 182-16.

If you are seeking an appeal of a decision by a PEBB Program health plan, insurance carrier, or benefit administrator, see How can I appeal a decision made by a plan? For example, you would contact your health plan to appeal a denial of a medical claim.

What is the appeals process?

The appeals process varies depending on your situation. Select your demographic to find the appeals process for your situation.

If your situation is:

Follow these instructions and submission deadlines:

You disagree with a decision made by your employer and you are requesting your employer's review about:

  • Premium surcharges
  • Eligibility for or enrollment in:
    • Medical
    • Dental
    • Life insurance
    • Long-term disability insurance
    • Medical Flexible Spending Arrangement (FSA)
    • Dependent Care Assistance Program (DCAP)

Instructions: Submit the Employee Request for Review/Notice of Appeal form to your employer.

 

Deadline: Your employer must receive the form no later than 30 calendar days after the date of the initial denial notice or decision you are appealing.

Your appeal concerns a decision made by your employer, and you are now requesting review of your employer’s decision.

Instructions: Submit the Employee Request for Review/Notice of Appeal form to the PEBB Appeals Unit as directed on the form, or follow these appeal rules.

Deadline: The PEBB Appeals Unit must receive the form no later than 30 calendar days after the date of your employer's review decision.

Your appeal concerns a decision from the PEBB Program about:

  • Eligibility and enrollment in:
    • Premium payment plan
    • Medical Flexible Spending Arrangement (FSA)
    • Dependent Care Assistance Program (DCAP)
    • Life insurance
  • Eligibility to participate in the SmartHealth Wellness Program or receive a wellness incentive
  • Dependent, extended dependent, or disabled dependent eligibility
  • Premium surcharges
  • Premium payments

Instructions: Submit the Employee Request for Review/Notice of Appeal form to the PEBB Appeals Unit as directed on the form, or follow these appeal rules.

Deadline: The PEBB Appeals Unit must receive the form no later than 30 calendar days after the date of the denial notice or decision you are appealing

  • A county
  • A municipality
  • A political subdivision
  • A tribal government
  • A school district
  • An educational service district
  • The Washington Health Benefits Exchange
  • An employee organization representing state civil service employees

If your situation is:

Follow these instructions and submission deadlines:

You disagree with a decision made by your employer and you are requesting your employer's review about:

  • Premium surcharges
  • Eligibility for or enrollment in:
    •  Medical
    • Dental

Instructions: Because you are a current or former employee of an employer group, contact your employer for information on how to appeal its decision or action and the required deadline to appeal.

Disagree with a decision by your employer, a PEBB insurance carrier, or the PEBB Program about:

  • Eligibility for or enrollment in:
    • Life insurance
    • Long-term disability insurance
  • Eligibility to participate in the SmartHealth Wellness Program or receive a wellness incentive

Instructions: Submit the Employee Request for Review/Notice of Appeal form to the PEBB Appeals Unit as directed on the form, or follow these appeal rules.

Deadline: The PEBB Appeals Unit must receive the form no later than 30 calendar days after the date of the denial notice or decision you are appealing

  • An applicant for PEBB retiree benefits

  • A retiree
  • A subscriber under PEBB Continuation Coverage
  • An applicant for PEBB Continuation Coverage
  • A survivor of a deceased employee or retiree as described in WAC 182-12-265 or 182-12-180
  • A survivor of emergency service personnel killed in the line of duty as described in WAC 182-12-250
  • The dependent of one of the above

If your situation is:

Follow these instructions and submission deadlines:

You disagree with a decision from the PEBB Program about:

  • Premium surcharges
  • Premium payments
  • Eligibility and enrollment in benefits
  • Eligibility to participate in the SmartHealth Wellness Program or receive a wellness incentive

Instructions: Submit the Retiree/PEBB Continuation Coverage Notice of Appeal form to the PEBB Appeals Unit as instructed on the form, or follow these appeal rules.

Deadline: The PEBB Appeals Unit must receive your appeal no later than 60 days after the date of the denial notice or decision you are appealing

How do I file an appeal?

Based on the group you belong to above, follow the instructions and submission deadlines for that type of appeal.

How do I appeal a decision made by a Presiding Officer?

You can appeal the PEBB Appeals Unit’s Presiding Officer’s Initial Order by filing a written request for review or by making an oral request for review.  Information detailing your right to request review is included in the PEBB Appeals Unit’s Presiding Officer’s Initial Order. Once your request for review is received by the Appeals Unit, a final order will generally be mailed within 20 days.

Mail to:
Health Care Authority
PEBB Appeals
PO Box 42699
Olympia, WA 98504-2699

Oral Request for review can be made by calling 1-800-351-6827.

Deadline: The PEBB Appeals Unit must receive your request for review no later than 21 calendar days after the service date of the Initial Order.

How do I appeal a decision made by a plan?

If you are seeking a review of a decision by a PEBB  health plan, insurance carrier, or benefit administrator, contact the plan to request information on how to appeal its decision. For example, you would contact your health plan to appeal a denial of a medical claim.

How can I make sure my personal representative has access to my health information?

You must provide the PEBB Program with a copy of a valid power of attorney or a completed Authorization for Release of Information form naming your representative and authorizing him or her to access your medical records and exercise your rights under the federal Health Insurance Portability and Accountability Act (HIPAA) of 1996.

Contact

PEBB Appeals unit
Phone:
1-800-351-6827
FAX: 360-725-0771

Mailing address:
PEBB Appeals
Health Care Authority
PO Box 42699
Olympia, WA 98504-2699

The PEBB Program