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Appeals process

General information and requirements

This information is applicable to personnel and payroll staff of state agencies and higher education institutions responding to appeals.

Note: The rules and procedures defined here do not apply to employer groups (including K-12s and ESDs) participating in PEBB benefits. See appeals process for employer groups for information on appeals process.

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.
  • PEBB staff are available to offer guidance in the process or applicable RCW, WAC, or PEBB policy.  PEBB Program staff won't make the decision for the employer.
  • An appeal is only necessary if there is a disagreement between the employer and the employee, or the employee agrees that a wrong decision or action occurred (outside of WAC 182-08-187).  However, the employer's position must reflect RCW, WAC, and PEBB policy. The state agency may only reverse eligibility, premium surcharge, or enrollment decisions based on circumstances that arose due to delay or errors caused by the state agency.
  • 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.  The employee should be directed to the instructions found on the form.
  • If correcting an enrollment error as described in WAC 182-08-187, forward your recommendation for correction of the enrollment error through FUZE for a final determination. If you key in the insurance system (Pay1) and cannot key the correct effective date (due to the lower limit date restrictions in Pay1), contact O&T via FUZE to key a day beyond the lower limit date.  Please do not key an incorrect effective date and then ask O&T to correct it.

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

  • For a decision made by the employing agency with regard to eligibility for benefits, enrollment, or the premium surcharge, the employee may submit a request for review of the decision to the employing agency by the process outlined in WAC 182-16-2020. See chart below.

  • For a decision made by the PEBB program with regard to eligibility for benefits, enrollment, premium payments, a premium surcharge, or eligibility to participate in the PEBB (SmartHealth) wellness incentive program or receive a PEBB wellness incentive, the current or former employee or employee's dependent may request a Brief Adjudicative Proceeding (BAP) by the process outlined in WAC 182-16-2030. See chart below.

  • For a decision made by a PEBB medical plan, dental plan, life insurance plan, or LTD insurance plan, the employee may appeal to the individual plan following the plan's procedures. The appeal may be about a claim or benefit (for example, a dispute about a course of treatment, billing, or reimbursement claim). Appeal procedures are included in the plan's Certificate of Coverage.

If the employee does not agree with a decision made by their state agency 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 state agency, in writing (the Request for Review/Notice of Appeal form) The from must be received by the agency no later than 30 calendar days after the date of the initial denial notice for the decision the employee is appealing. The state agency 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 state agency 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 5 through 7 (as applicable) of the Request for Review/Notice of Appeal form.

Section 5: Employer Response to Employee's Request for Review

Section 6: Employer Response When the Employer Agrees a Wrong Decision or Action Occurred (if applicable)

Section 7: Employer Signature

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

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

Employee may... ...no later than... ...and then
Complete section 8 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 5 of the Request for Review/Notice of Appeal form

A Presiding Officer generally will 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 written 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.

Guidance resources

Forms

WAC references and their general subject matter

  • 182-16-020 - Definitions
  • 182-16-2010 - Where do members appeal decisions regarding eligibility, enrollment, premium payments, or the administration of benefits?
  • 182-16-2020 - How can a current or former employee or an employee's dependent appeal a decision made by a state agency about eligibility, premium surcharge, or enrollment in benefits?
  • 182-16-2030 - How can an employee, retiree, self-pay enrollee, or dependent appeal a decision made by the PEBB program regarding eligibility, enrollment, or premium payments?
  • 182-16-2040 - How can a subscriber appeal a decision regarding the administration of wellness incentive program requirements?
  • 182-16-2050 - How can an employee who is eligible to participate in the state's salary reduction plan appeal a decision regarding the administration of benefits offered under the state's salary reduction plan?
  • 182-16-2070 - What should a written request for administrative review and a request for brief adjudicative proceeding contain?
  • 182-16-2085 - Continuances
  • 182-16-2090 - Initial order
  • 182-16-2100 - How to request a review of an initial order resulting from a brief adjudicative proceeding.
  • 182-16-2110 - Final order
  • 182-12-2120 - Request for reconsideration