Appeals process

This information is applicable to benefit administrators responding to appeals.

Note: The rules and procedures defined here do not apply to Educational Service Districts who have non represented employees 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 SEBB policies (including those in SEBB publications) are followed. This applies to the original decision made by the SEBB organization, as well as, responses to any appeals considered.

  • SEBB Program staff are available to offer guidance in the process or applicable RCW, WAC, or SEBB policy.  SEBB Program staff won't make the decision for the SEBB organization.
  • An appeal is only necessary if there is a disagreement between the SEBB organization and the employee.  However, the employer's position must reflect RCW, WAC, and SEBB policy. The SEBB organization may only reverse eligibility, premium surcharge, or enrollment decisions based on circumstances that arose due to delay or errors caused by the SEBB organization.
  • When an employee disagrees with a decision made by the SEBB organization, 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.
  • An employee who disagrees with their employer’s written decision in response to a request for administrative review 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 SEBB appeals unit.  The employee should be directed to the instructions found on the form. The employer should not send the appeal on the employee’s behalf.
  • If correcting an enrollment error as described in WAC 182-30-060, forward your recommendation for correction of the enrollment error through FUZE for a final determination. If you cannot enter the correct effective date in SEBB My Account (due to the lower limit date restrictions), 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 SEBB organization with regard to eligibility for benefits, enrollment, or the premium surcharge, the employee may submit a request for review of the decision to the SEBB Organization by the process outlined in WAC 182-32-2020. See chart below.
  • For a decision made by the SEBB program with regard to eligibility for benefits, enrollment, premium payments, a premium surcharge, or eligibility to participate in the SEBB (SmartHealth) wellness incentive program or receive a SEBB wellness incentive, the current or former employee or employee's dependent may request a Brief Adjudicative Proceeding (BAP) by the process outlined in WAC 182-32-2030. See chart below.
  • For a decision made by a SEBB medical plan, dental plan, vision plan, life and accidental death and dismemberment (AD&D) 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 SEBB organization 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 organization in writing (the Employee Request for Review/Notice of Appeal form​)

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

The SEBB organization shall render a written decision on the Employee Request for Review/Notice of Appeal form​ no later than 30 calendar days after receiving the request for review.

When the SEBB organization receives the Employee 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 Employee Request for Review/Notice of Appeal form​.

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

Section 5: Employer Response When the Employer Agrees a Wrong Decision or Action Occurred (if applicable)

Section 6: Employer Signature

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

Send a copy of the decision to:

  • Your organization administrator or designee, and
  • Employee

If the employee does not agree with the organizations final decision, the:

Employee may...

...no later than...

...and then

Complete section 7 of their Employee Request for Review/Notice of Appeal form​ and submit to the SEBB Appeals Unit at the address listed on the form

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

A Presiding Officer generally will render a written initial order within 10 business days of receiving the Employee 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 SEBB 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.

Contact

SEBB Appeals Unit
Phone:
 1-800-351-6827
Fax: 360-586-9080
Mailing address:
Health Care Authority
Attn: SEBB Appeals Unit
PO Box 45504
Olympia, WA 98504-5504