Appeals Process

Appeals Process

Print Email

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.

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

None

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