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. To find out the appeals process for your situation, you must first find the group you belong to from the list below.

Group 1 – I am a state agency or higher-education employee (or his or her dependent). Go to How do I file an appeal?

Group 2 – I am an employer group employee (or his or her dependent) of:

  • 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

Go to How do I file an appeal?

Group 3 – I am:

  • An applicant for PEBB benefits
  • A retiree
  • A subscriber under COBRA, PEBB Continuation Coverage
  • A survivor of a deceased employee or retiree as described in WAC 182-12-265
  • 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

Go to How do I file an appeal?

How do I file an appeal?

Based on the group you belong to above, find your type of appeal listed below. Follow the instructions and submission deadlines for that type of appeal.

Group 1

Depending on who made the specific decision or denial you are appealing, your employer’s personnel, payroll, or benefits office, or the PEBB appeals manager must receive your appeal form no later than 30 calendar days after the date of the denial notice for the decision you are appealing.

Type 1

If your appeal concerns 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

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.

Type 2

If your appeal concerns a decision by your employer in response to your request for your employer's review, and you are now requesting an appeal of your employer's decision by the PEBB Appeals Committee.

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

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

Type 3

If your appeal concerns a decision from the PEBB Program about:

  • Eligibility and enrollment in a:
    • Premium payment plan
    • Medical Flexible Spending Arrangement (FSA)
    • Dependent Care Assistance Program (DCAP)
  • 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 Manager as directed on the form, or follow these appeal rules.

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

Group 2

Type 1

If your appeal concerns a decision by your employer about:

  • Premium surcharges
  • Eligibility for or enrollment in medical and dental

Instructions: Contact your employer for information on how to appeal its decision or action and the required deadline to appeal.

Type 2

If your appeal concerns a decision by your employer, a PEBB insurance carrier, or the PEBB Program about:

  • Eligibility for or enrollment in life insurance
  • Eligibility for or enrollment in 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 Manager as directed on the form, or follow these appeal rules.

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

Group 3

If your appeal concerns 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/COBRA/PEBB Continuation Coverage Notice of Appeal form to the PEBB Appeals Manager as instructed on the form, or follow these appeal rules.

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

How do I appeal a decision made by the PEBB Appeals Committee?

You can appeal a decision by the PEBB Appeals Committee by requesting an administrative hearing before an Administrative Law Judge (ALJ) at the Office of Administrative Hearings (OAH), a separate, independent state agency. Information on administrative hearing rights is included in the written decision letter you receive from the PEBB Appeals Committee. You must submit your request for an administrative hearing in writing to the PEBB Appeals Manager.

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

Once the PEBB Appeals Manager receives your written request for review by the OAH, the request will be forwarded to OAH for assignment to an ALJ. Once an ALJ has been assigned, the OAH will send further instructions about the appeal process.

Deadline: The PEBB Appeals Manager must receive your written request for an administrative hearing no later than 30 calendar days after the date of the PEBB Appeals Committee's decision.

How do I appeal a decision made by a plan?

If you are seeking a review of a decision by a PEBB Program 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 of 1996.

Contact

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

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

The PEBB Program