Appeals process

This information is applicable to benefit administrators responding to employee appeals.

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General guidance for SEBB Organization (employer) level appeals

  • The employer is responsible for making all eligibility or enrollment decisions to ensure that RCW, WAC, and SEBB policies (including those in SEBB 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 appeals process or applicable RCW, WAC, or SEBB policy. However, O&T cannot make the decision for the SEBB organization.
  • "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 the SEBB organization, they can request an employer 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. See the instructions for employer's steps when receiving the request. 
  • 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 SEBB 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 SEBB Organization agrees with the employee that a wrong decision or action occurred?

The SEBB Organization resolves the issue without continuing the appeals process. Neither the organization nor the employee should submit an appeal to the SEBB 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 SEBB Organization 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 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, or in the table 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, or in the table 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.
  • For a decision made by the SEBB 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 182-32-2040.
  • 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 182-32-2050.

Appealing a SEBB organization'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 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 using the Employee Request for Review/Notice of Appeal form.

The from must be received by the SEBB organization no later than 30 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 days after receiving the request for review.

Receiving the Request for Review/Notice of Appeal form

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​.

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 SEBB appeals unit.

The SEBB 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. 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 SEBB Appeals unit

If the employee does not agree with the organization'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 Employee Request for Review/Notice of Appeal form​ and submit to the SEBB 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 Employee 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 SEBB appeals unit must notify the employee in writing that the request has been received.

The SEBB 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 generally will render a written initial order within 10 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.

Appealing a SEBB Program decision

If the current or former employee does not agree with a decision made by the SEBB Program regarding eligibility, enrollment, premium payments, premium surcharges, or a SEBB wellness incentive as described in WAC 182-32-2030 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 182-32-2070 to the SEBB Appeals Unit or submit the Benefits Appeal Request form through the online appeals portal.

 

The request must be received by the SEBB 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 SEBB 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, SEBB Program decision, or contracted vendor decision resulting from a BAP

To request a review of an initial order upholding an employer decision, SEBB Program decision, or a decision made by a SEBB Program contracted vendor as described in WAC 182-32-2100 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 date 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 SEBB appeals unit (whichever is later) the review officer will issue a final order that will include a notice that reconsideration (WAC 182-32-2120) 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 SEBB 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 182-32 for a complete list of Appeals Practice and Procedures.