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Information to assist benefits administrators of employer groups when responding to employee appeals.
Looking for information about the appeals process for agencies and higher ed?
If a current or former employee does not agree with a decision made by their employer about eligibility for benefits, enrollment, or premium surcharges and wishes to appeal, the:
Employee must... | ...within the... | ...and then |
---|---|---|
Submit the appeal to the employer through the process established by the employer. | Timeline defined by the employer. | The employer must make a decision congruent with the employer’s contract with HCA, RCW, WAC, and PEBB policy. |
A current of former employee may appeal the following types of decisions by submitting a request to the PEBB appeals unit for a BAP to be conducted by the authority as described in WAC 182-16-2030.
Employee must... | ...no later than... | ...and then |
---|---|---|
Submit a request for a brief adjudicative proceeding that contains the information found in WAC 182-16-2070 to the PEBB Appeals Unit or submit the Benefits Appeal Request form through the online appeals portal. |
The request must be received by the PEBB Appeals Unit no later than 30 days after the date of the initial denial notice for the decision the employee is appealing. Failing to timely request a brief adjudicative proceeding will result in the prior PEBB program decision becoming the authority's final order without further action. |
A Presiding Officer will generally render a written initial order within 10 days of receiving the request for a BAP. The presiding officer must serve a copy of the initial order on all parties and the initial order must contain information on how the appellant may request review of the initial order. The Presiding Officer may extend the 10-day time requirement for rendering a decision if a continuance is granted. The employee will be notified in writing if an extension is required. |
To request further review of an initial order upholding an employing agency decision, PEBB Program decision, or a decision made by a PEBB Program contracted vendor, the:
Employee (appellant) may... | ...no later than... | ...and then |
---|---|---|
File a written request for review or make an oral request for review of the initial order. The request for review must be provided using the contact information included in the initial order. |
21 days after the service of the initial order. If the employee fails to request the review within 21 days, the initial order becomes the authority's final order without further action. |
Generally, within 20 days of the date of the initial order or of the date of the request for review of the initial order was received by the PEBB appeals unit (whichever is later) the review officer will issue a final order that will include a notice that reconsideration (WAC 182-16-2120) and judicial review may be available. A copy of the final order will be mailed to all parties. |
The employee may withdraw a request for a BAP or review of an initial order for any reason.
Employee (appellant) may... | when | ...and then |
---|---|---|
Withdraw their request/review for any reason, by submitting a request in writing to the PEBB appeals unit. |
At any time |
The presiding officer or officers must enter and serve a written order dismissing the BAP or review of the initial order. The appellant may not reinstate the request for a BAP or review of initial order unless time remains on their original appeal period. |
See WAC 182-16 for a complete list of Appeals Practice and Procedures.
Outreach and Training
Benefits administrators contact O&T for eligibility, enrollment, or billing related questions.
Phone: 1-800-700-1555
Secure messaging: HCA Support