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Appeals process for employer groups

General Information and Requirements

Updated 3/2021

"Employer Group" means any of the following that are obtaining employee benefits through contractual agreement with the Health Care Authority (HCA) as described in WAC 182-08-245.

  • Counties, Municipalities, Political subdivisions
  • K-12 Public School districts and Educational service districts with employees enrolled in PEBB (and not SEBB benefits).
  • Employee organizations representing state civil service employees.
  • The Washington Health Benefit Exchange
  • Tribal governments

This information is applicable to personnel responsible for responding to appeals.

Note: The rules and procedures defined here do not apply to state agencies (including state higher education institutions).

General Guidance for Employer Level Appeals

  • The employer is responsible for making all eligibility or enrollment decisions and 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 associated to applicable RCW, WAC, or PEBB policy, however, PEBB 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. If there is no disagreement, no appeal is necessary. However, the employer's decision must be congruent with the contract with HCA, RCW and WAC.
  • The employing agency may make the correction retroactively as far back as the lower limit date. If correcting an enrollment error as described in WAC 182-08-187, forward your recommendation through FUZE for a final determination. If you key in the insurance system (PAY1), and cannot key the correct effective date, contact O&T to key a date 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 an employer group with regard to PEBB eligibility, enrollment, or premium surcharges, any current or former employee or their dependent may appeal that decision to the employer group through the process established by the employer group. (WAC 182-16-2010 (2))
    • Exception: For decisions involving eligibility or enrollment in life insurance and LTD insurance, eligibility to participate in the PEBB 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 with regard to PEBB eligibility, enrollment, premium payments, premium surcharges, eligibility to participate in the PEBB wellness incentive program or to receive a PEBB wellness incentive, the subscriber or dependent may appeal to the PEBB appeals unit by the process described in WAC 182-16-2030. (WAC 182-16-2010 (3))
  • For a decision made by a PEBB medical plan, dental plan, life insurance plan, LTD insurance plan, long-term care insurance plan, or property and casualty insurance plan , the PEBB enrollee may appeal to the individual plan according to 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.
  • 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, any subscriber may appeal by the process described in WAC 182-16-240.

Eligibility and Enrollment Appeals

If an employee does not agree with a decision about eligibility or enrollment in medical and/or dental made by their employer 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, and WAC

If an employee does not agree with a decision about eligibility or enrollment in life insurance, long-term disability 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 30 calendar days after the date of the employer’s denial notice

A Presiding Office will generally issue render an initial order within 10 business days of receiving the notice of appeal.

The Presiding Office 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 Presiding Offices initial order and wishes to request further review, the:

Employee must... ...no later than... ...and then

Request a review orally or in writing. Instructions for requesting review are contained in the initial order.  Call or send the request and copies of all supporting documentation to the address or phone number given on the initial order.

PEBB Appeals unit

Health Care Authority

PO Box 42699

Olympia, WA 98504-2682

21 calendar days after the date of the initial order. Within 20 days after the request of review was received, the review officer shall mail a final order to all parties.  This order is the final decision of the authority. 

Guidance Resources

  • Lower Limit and Current Process Calendar  2020 | 2021

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?
  • 182-16-2030 - Appealing a public employees benefits board (PEBB) program decision regarding eligibility, enrollment, premium payments, premium surcharges, a PEBB wellness incentive, or certain decisions made by an employer group?
  • 182-16-2040 - How can a subscriber appeal a decision regarding the administration of wellness incentive program requirements?
  • 182-16-2070 - What should a written request for administrative review and a request for brief adjudicative proceeding contain?
  • 182-16-2160 - Conversion of a brief adjudicative proceeding to a formal administrative hearing.