Appeals process

Find guidance on the appeals process for benefits administrators of state agencies and institutions of higher education.

Are you a benefits administrator of an employer group?

The rules and procedures defined on this page do not apply to employer groups (including K-12 school districts with board members enrolled in PEBB and Educational Service Districts) participating in PEBB benefits. Visit the Appeals process for employer groups page for guidance.

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 reflect 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. Learn about correcting employer errors.
  • The employee has 30 days from the date of the employer decision to request a Brief Adjudicative Proceeding (BAP) by sending the completed Employee Request for Review/Notice of Appeal form to the PEBB appeals unit. Direct the employee to following the instructions provided on the form.

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

  • For a decision made by the employer 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 outlined in WAC 182-16-2020 and in the table below.
  • 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 it's 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.
  • For a decision made regarding the administration of benefits offered under the salary reduction plan (FSAs and DCAP), the employee may submit a request for review of the decision to the employer by the process outlined in WAC 182-16-2050.

If the 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... ...no later than... ...and then
Request a review by their employer, in writing, using the Request for Review/Notice of Appeal form. The from must be received by the employer no later than 30 calendar days after the date of the initial denial notice for the decision the employee is appealing. The employer shall render a written decision on the Request for Review/Notice of Appeal form no later than 30 calendar days after receiving the request for review.

When the employer receives the Request for Review/Notice of Appeal form:

Employer must... ...no later than... ...and then

Have one or more staff who were not involved in the initial decision, make a complete review of the denial and complete sections 4 through 6 (as applicable) of the Request for Review/Notice of Appeal form.

Section 4: Employer Response to Employee's Request for Review

Section 5: Employer Response to be completed only when the employer agrees a wrong decision or action occurred.

Section 6: Employer Signature

30 calendar days after the date the request for review is received Send a copy of the decision to:
  • The employer's administrator or designee, and
  • Employee, and
  • PEBB appeals unit

If the employee does not agree with the employer's final decision, the:

Employee may... ...no later than... ...and then
Complete section 7 of their Request for Review/Notice of Appeal form and submit to the PEBB Appeals Unit at the address listed on the form 30 calendar days after the agency decision date in section 4 of the Request for Review/Notice of Appeal form

A Presiding Officer 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 the 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.

Related rules and policies

  • WAC 182-16-2010: Appealing a decision regarding PEBB eligibility, enrollment, premium payments, premium surcharges, a wellness incentive, or the administration of benefits. 
  • WAC 182-16-2020: Appealing a decision made by a state agency about eligibility, premium surcharges, or enrollment in 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 182-16-2050: How can an employee appeal a decision regarding the administration of benefits offered under the salary reduction plan?
  • 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