SEBB Program appeals should go to employers first

Wed, 02/19/2020

School employees submitting appeals about their School Employees Benefits Board (SEBB) Program benefits should ensure they follow the correct process by sending their appeal to their employer first.

Starting March 1, 2020, most appeals about eligibility or enrollment should go to the employee’s payroll or benefits office. Learn more about when and how to file an appeal on our SEBB appeals webpage and SEBB Employee Request for Review/Notice of Appeal form.

The Health Care Authority (HCA) received appeals in response to decisions made during the SEBB Program’s first annual open enrollment (October 1–November 15, 2019), and we are still working through them. However, any plan change requests must first be denied by your payroll or benefits office before appealing to HCA.

Any employee who files an appeal with HCA on or after March 1, 2020 will be sent a letter notifying them that their appeal should first be filed with their employer’s payroll or benefits office.

What if I already filed an appeal?

Employees who have already filed an appeal with HCA do not need to file another appeal with their payroll or benefits office.

For appeals received by HCA on or before February 29, employees will be sent a letter that will state either:

  • The appeal was approved; OR

  • Information about next steps in the appeals process.

How do I submit an appeal regarding eligibility or enrollment after February 29?

Starting March 1, if you want to appeal a decision by your employer, you must first submit the SEBB Employee Request for Review/Notice of Appeal form to your organization's payroll or benefits office for review and/or a decision. See the File and appeal: SEBB webpage for more information.

How do I submit an appeal of a denial of a medical claim?

Contact your health plan. See How do I appeal a decision made by a plan?

What if my appeal is denied by my payroll or benefits office, and I don't agree?

You can appeal to HCA. Instructions on how to appeal are on the SEBB Employee Request for Review/Notice of Appeal form.

How do I confirm my enrollment? How do I confirm my dependents' enrollment?

Refer to your Statement of Insurance found in SEBB My Account.

What if there's a mistake on my enrollment and I didn't realize it until after February 29?

You can appeal to your payroll or benefits office. If they deny it, you can appeal to HCA.

I filed an appeal to change my dental plan from DeltaCare to Uniform Dental Plan. What's next?

All plan change request appeals related to the letter Delta Dental sent in mid-December 2019 will be approved if postmarked or received on or before February 29. HCA and Delta Dental will honor the request to switch from DeltaCare to Uniform Dental Plan.

If you submitted your appeal by February 29, you will receive a letter confirming the approval with coverage effective back to January 1, 2020. Requests to change plans received with a postmark date of after February 29 will not be approved unless there is a special open enrollment event that allows for the plan change.

How do I find out the status of appeals filed by February 29?

Please be assured the SEBB Program is working through the appeals received as quickly as possible. If approved, coverage will be effective back to January 1, 2020.

For appeals postmarked or submitted on or before February 29, call 1-800-200-1004 (menu option 7) from 8 a.m. to 4:30 p.m., Monday through Friday.

For appeals submitted after February 29, contact your payroll or benefits office.

What if my appeal is an emergency?

If you feel your life, health, or safety is at risk, you should seek care immediately.

Call 1-800-200-1004 (menu option 7) from 8 a.m. to 4:30 p.m., Monday through Friday if you have an urgent medical need for physical health, mental health, and substance use disorder services such as:

  • Urgent care or emergency care visits.
  • Hospital admissions.
  • A surgery or procedure needed within the next 10 calendar days.
  • A medication refill needed within the next 10 calendar days.

When you call, tell the customer service representative that you or your dependent have an urgent medical need requiring an expedited appeal decision. An HCA account manager will contact you by phone or email (generally the same day but within one business day) and work with you until a resolution on the appeal is reached. If the situation occurs outside of HCA business hours, contact HCA the following business day.