Appeals process for employer groups

Information to assist benefits administrators of employer groups when responding to employee appeals.

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General guidance for employer level appeals

The employer is responsible for making all eligibility or enrollment decisions is to ensure that RCW, WAC, and PEBB policies (including those in PEBB publications) are followed. This applies to the original decision made by the employer, as well as responses to any appeals considered.
Outreach and Training (O&T) staff are available to offer guidance in the process or applicable RCW, WAC, or PEBB policy. However, O&T cannot make the decision for the employer.
An appeal is only necessary if there is a disagreement between the employer and the employee, or the employer agrees that a wrong decision or action occurred (outside of WAC 182-08-187). However, the employer's decision must align with the contract/interlocal agreement with the Health Care Authority (HCA), RCW, WAC, and PEBB policy.
The employer may only reverse eligibility, premium surcharge, or enrollment decisions based on circumstances that arose due to delay or errors caused by the employer per WAC 182-08-187.

‌What if the employer agrees with the employee that a wrong decision or action occurred?

The employer resolves the issue without continuing the appeals process. Neither the employer nor the employee should submit an appeal to the PEBB Program.
Employers can correct their errors in the insurance system if the effective date of the correction falls within the lower limit period. If the effective date of the correction falls outside the lower limit period, or if the employer does not enter enrollment in the insurance system, the employer must contact Outreach and Training through HCA Support to make the correction.

Where do current or former employees and their dependents appeal decisions?

For a decision made by an employer group regarding eligibility for PEBB benefits, enrollment, or premium surcharges, the employee may submit a request for review of the decision to the employer by the process established by the employer group. (WAC 182-16-2010 (2))
- Exception: For decisions involving life, AD&D, and LTD insurances, eligibility to participate in the PEBB (SmartHealth) wellness incentive program, or eligibility to receive a PEBB wellness incentive, a current or former employee of an employer group may appeal to the PEBB Appeals Unit by the process described in WAC 182-16-2030.
For a decision made by the PEBB program regarding PEBB eligibility for benefits, enrollment, premium payments, premium surcharges, eligibility to participate in the PEBB (SmartHealth) wellness incentive program, or eligibility to receive a PEBB wellness incentive, the current or former employee or their dependent may request a Brief Adjudicative Proceeding (BAP) by the process outlined in WAC 182-16-2030 and in the table below.
For a decision made by a PEBB health plan (medical, dental life, AD&D, or LTD), the employee may appeal to the individual plan following the plan's procedures. For example, the appeal may be about a claim denial, a course of treatment, or billing. Contact the plan to request information on how to appeal its decision.
For a decision made by the PEBB wellness incentive program contracted vendor regarding the completion of the program requirements, or a request for a reasonable alternative to a wellness incentive program requirement, an employee or their dependent may appeal by the process described in WAC 182-16-2040.

If an 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.

If an employee does not agree with a decision about eligibility or enrollment in life, AD&D, or LTD insurance, eligibility to participate in PEBB wellness incentive program, or eligibility to receive a PEBB wellness incentive, and wishes to appeal, the:

Employee must...	...no later than...	...and then
Submit the Request for Review/Notice of Appeal form to the PEBB Appeals Unit.	The from must be received by the PEBB Appeals Unit no later than 30 calendar days after the date of the initial denial notice for the decision the employee is appealing.	A Presiding Office will generally render a written initial order within 10 business days of receiving the Request for Review/Notice of Appeal form. 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.

Employee must...

...no later than...

...and then

Submit the Request for Review/Notice of Appeal form to the PEBB Appeals Unit.

The from must be received by the PEBB Appeals Unit no later than 30 calendar days after the date of the initial denial notice for the decision the employee is appealing.

A Presiding Office will generally render a written initial order within 10 business days of receiving the Request for Review/Notice of Appeal form.

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.

If an employee does not agree with the initial order and wishes to request further review, the:

Employee 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 calendar days after the date of the initial order.	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.

WAC references and their general subject matter

WAC 182-16-2010: Appealing a decision regarding PEBB eligibility, enrollment, premium payments, premium surcharges, a wellness incentive, or the administration of benefits.
WAC 182-16-2030: Appealing a PEBB program decision regarding eligibility, enrollment, premium payments, premium surcharges, a PEBB wellness incentive, or certain decisions made by an employer group.
WAC 182-16-2040: How can a subscriber appeal a decision regarding the administration of wellness incentive program requirements?
WAC 182-16-2070: What should a written request for administrative review and a request for brief adjudicative proceeding contain?
WAC 182-16-2085: Continuances.
WAC 182-16-2090: Initial order.
WAC 182-16-2100: How to request a review of an initial order resulting from a brief adjudicative proceeding.
WAC 182-16-2110: Final order.
WAC 182-12-2120: Request for reconsideration.

Contact

Outreach and Training
Benefits administrators contact O&T for eligibility, enrollment, or billing related questions.
Phone: 1-800-700-1555
Secure messaging: HCA Support