Appeals process

Information to assist benefits administrators of state agencies and institutions of higher education when responding to employee appeals.

Looking for information about the appeals process for employer groups?

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.
"Days" or "calendar days" means all days including Saturdays, Sundays, and all state legal holidays as set forth in RCW 1.16.050.
When an employee disagrees with a decision made by their employer, they can request an administrative review of that decision by completing sections 1-3 of the Employee Request for Review/Notice of Appeal form and submitting it to their organization’s payroll or benefits office no later than 30 days after the date of the initial denial notice/decision they are appealing.
The employee has 30 days from the date of the employer decision to request a Brief Adjudicative Proceeding (BAP) by submitting either:
- The completed Employee Request for Review/Notice of Appeal form to the PEBB appeals unit. Direct the employee to follow the instructions provided on the form. The employer should not send the appeal on the employee’s behalf. OR
- The Benefits Appeal Request form through the online appeals portal at HCA Support.
  - Select "Public Inquiry" from the HCA Support homepage, and log in to SAW.
  - Select "Make a Request" and choose the "Benefits Appeal Request" option. Fill out the form.

‌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. Learn how to correct employer errors. If the effective date of the correction falls outside the lower limit period 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 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.

Appealing an employer's decision about eligibility for benefits, enrollment, or premium surcharges

If the 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...	...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 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 days after receiving the request for review.

Receiving the Request for Review/Notice of Appeal form

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

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. Complete section 4: Employer Response to Employee's Request for Review Complete section 5: Employer response if the employer agrees that a wrong decision or action occurred, due to employer delay or error. If the employer stands by their initial decision (the denial), skip section 5. Complete section 6: Employer Signature	30 days after the date the request for review is received. If the employer fails to render a written decision within 30 days, the request for administrative review may be considered denied as of the 31st day, and the original underlying decision may be appealed to the PEBB appeals unit. The PEBB appeals unit must receive the request for a Brief Adjudicative Proceeding (BAP) no later then 30 days after the request for administrative review was deemed denied.	If the employer agrees that a wrong decision or action occurred due to employer delay or error, the appeals process ends, and the employer must correct the error. The employer may reverse eligibility, premium surcharges, or enrollment decisions as permitted by WAC 182-08-187 Learn how to correct employer errors. If the employer stands by the denial, provide a copy of the Employee Request for Review/Notice of Appeal form with sections 4 and 6 completed to: Your organization administrator or designee, and The employee.

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.

Complete section 4: Employer Response to Employee's Request for Review

Complete section 5: Employer response if the employer agrees that a wrong decision or action occurred, due to employer delay or error. If the employer stands by their initial decision (the denial), skip section 5.

Complete section 6: Employer Signature

30 days after the date the request for review is received.

If the employer fails to render a written decision within 30 days, the request for administrative review may be considered denied as of the 31st day, and the original underlying decision may be appealed to the PEBB appeals unit.

The PEBB appeals unit must receive the request for a Brief Adjudicative Proceeding (BAP) no later then 30 days after the request for administrative review was deemed denied.

If the employer agrees that a wrong decision or action occurred due to employer delay or error, the appeals process ends, and the employer must correct the error. The employer may reverse eligibility, premium surcharges, or enrollment decisions as permitted by WAC 182-08-187 Learn how to correct employer errors.

If the employer stands by the denial, provide a copy of the Employee Request for Review/Notice of Appeal form with sections 4 and 6 completed to:

Your organization administrator or designee, and
The employee.

Employee notice of appeal to the PEBB Appeals Unit

If the employee does not agree with the employer or PEBB Program's final decision and wishes to request a Brief Adjudicative Proceeding (BAP), 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 or submit the Benefits Appeal Request form through the online appeals portal.	30 days after the agency decision date in section 4 of the Request for Review/Notice of Appeal form. If the employee fails to timely submit the form, the employer's prior written decision becomes the final order without further action.	The PEBB appeals unit must notify the employee in writing that the request has been received. The PEBB appeals unit will send a request for documentation and information to the applicable employer, who will then have 2 business days to provide the requested information and documentation to the appeals unit and the employee. A Presiding Officer will generally render a written initial order within 10 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 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 or submit the Benefits Appeal Request form through the online appeals portal.

30 days after the agency decision date in section 4 of the Request for Review/Notice of Appeal form.

If the employee fails to timely submit the form, the employer's prior written decision becomes the final order without further action.

The PEBB appeals unit must notify the employee in writing that the request has been received.

The PEBB appeals unit will send a request for documentation and information to the applicable employer, who will then have 2 business days to provide the requested information and documentation to the appeals unit and the employee.

A Presiding Officer will generally render a written initial order within 10 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.

Appealing a PEBB Program decision

If the current or former employee does not agree with a decision made by the PEBB Program regarding eligibility, enrollment, premium payments, premium surcharges, or a PEBB wellness incentive as described in WAC 182-16-2030 the...

Employee may request a Brief Adjudicative Proceeding (BAP)...	...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.

Employee may request a Brief Adjudicative Proceeding (BAP)...

...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.

Requesting review of an initial order upholding an employer decision, PEBB Program decision, or contracted vendor decision resulting from a BAP

To request a review of an initial order upholding an employer decision, PEBB Program decision, or a decision made by a PEBB Program contracted vendor as described in WAC 182-16-2100 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 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.

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 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.

Withdrawing a request for a BAP or review of initial order

The employee may withdraw a request for a BAP or review of an initial order for any reason.

Employee may...	when	...and then
Contact the PEBB appeals unit and request in writing the withdrawal of their request.	At any time	The presiding officer must enter and serve a written order dismissing the BAP or review of the initial order. The employee 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.

We’re stabilizing Benefits 24/7

Appeals process

On this page

General guidance for employer level appeals

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

Appealing an employer's decision about eligibility for benefits, enrollment, or premium surcharges

Receiving the Request for Review/Notice of Appeal form

Employee notice of appeal to the PEBB Appeals Unit

Appealing a PEBB Program decision

Requesting review of an initial order upholding an employer decision, PEBB Program decision, or contracted vendor decision resulting from a BAP

Withdrawing a request for a BAP or review of initial order

Contact

We’re stabilizing Benefits 24/7

Appeals process

On this page

General guidance for employer level appeals

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

Appealing an employer's decision about eligibility for benefits, enrollment, or premium surcharges

Receiving the Request for Review/Notice of Appeal form

Employee notice of appeal to the PEBB Appeals Unit

Appealing a PEBB Program decision

Requesting review of an initial order upholding an employer decision, PEBB Program decision, or contracted vendor decision resulting from a BAP

Withdrawing a request for a BAP or review of initial order

Contact

Related forms and publications

Related links