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Appeals Process

General Information and Requirements

Updated 3/19/2009

Applicable to:

  • Personnel and Payroll staff responding to appeals.
  • Employees appealing an eligibility or enrollment decision made by their employing agency.

General Guidance for Employer Level Appeals

  • The employer’s charge in making all eligibility or enrollment decisions is to ensure that RCW, WAC, and PEBB policies (including those in various PEBB publications) are followed. This applies to the original decision made by the employer, as well as, responses to any appeals considered.
  • PEBB staff is available to offer guidance in the process or applicable RCW, WAC, or PEBB policy but, 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, as noted above, the employer’s position must reflect RCW, WAC, and PEBB policy. That being said, the employing agency may only reverse eligibility and enrollment decisions based on circumstances that arose due to delay or errors caused by the employing agency.
  • The employing agency may make the correction in PAY1 as far back as the lower limit date (90 days). Corrections that require an effective date prior to the lower limit date (90 days) must be submitted to PEBB for keying. Please submit your correction request through FUZE. Please don’t key back as far as you can and then contact us to key back to the actual effective date of the change. Contact us first and we’ll make the effective date change for you.

If the employee does not agree with a decision about eligibility or enrollment made by their employing agency and wishes to appeal, the:

Employee must... ...within... ...and then
Request a review by their agency, in writing (form is available on the PEBB website) 30 days of the agency's decision The employer has 30 days to review the request

When the agency receives a Request for Review the:

Employer must... ...within... ...and then
Have at least one or more staff, not involved in the initial decision, make a complete review of the request and complete an Employer Decision Notice (form on Pers/Pay website) 30 days of the date the request for review is submitted Send a copy of the decision to:
  • Your agency administrator or designee
  • Employee
  • PEBB appeals manager

 

Agency administrator or designee may... ...within... ...and then
Overturn the decision 15 days of the date on the decision Send a copy of the new decision to:
  • Employee
  • PEBB appeals manager
  • Employing agency

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

Employee may... ...within... ...and then
Submit a Notice of Appeal to the PEBB Appeals Committee 30 days of the date on the Employer Decision Notice The appeals committee has 30 days to review the appeal and respond, in writing, to the employee

If the employee does not agree with the PEBB Appeals Committee decision and wishes to request a hearing, the:

Employee may... ...within... ...and then
Request an Administrative Hearing in writing. Send request and copies of all supporting documentation to the:
PEBB Appeals Manager
Health Care Authority
PO Box 42684
Olympia, WA 98504-2682
30 days of the postmark on the appeals committee decision The administrator or designee will render a decision within 90 days after the hearing. A copy of the decision will be sent to the employee and the employer

Guidance Resources

Forms

System Keying in PAY1

None

Common Questions and Answers

Html I found an LTD form in my employee's file and it was not enrolled online. How should I handle this?

WAC References and their general subject matter

  • Html 182-16-030 How can an employee appeal a decision made by an employing agency about eligibility or enrollment in benefits?
  • Html 182-16-034 How can a PEBB enrollee appeal a decision regarding administration of a PEBB plan?
  • Html 182-16-036 How can an enrollee appeal a decision regarding the administration of their FSA or DCAP account?
  • Html 182-16-037 How can an enrollee appeal a decision by the agency's self-insured dental plan?
  • Html 182-16-040 What should a request for review or notice of appeal contain?
  • Html 182-16-050 How can an enrollee or entity get a hearing if aggrieved by a decision made by the PEBB appeals committee?