File an appeal: PEBB

Find out how you can appeal a decision or denial by your employer or the Public Employees Benefits Board (PEBB) Program.

Who can appeal?

If you are a subscriber, dependent, or applicant for PEBB benefits, you may be able to file an appeal of a decision made by your employer or the PEBB Program. The rules for filing an appeal are in Chapter 182-16 WAC.

If you are seeking an appeal of a decision by a PEBB medical or dental plan, insurance carrier, or benefit administrator, see How can I appeal a decision made by a plan? For example, you would contact your health plan to appeal a denial of a medical claim.

What is the appeals process?

The appeals process varies depending on your situation. Select your demographic to find the appeals process for your situation.

State agency or higher-education employee (or their dependent)
If your situation is: Follow these instructions and submission deadlines

You disagree with a decision made by your employer and are requesting your employer's review about:

  • Premium surcharges
  • Eligibility or enrollment in:
    • A premium payment plan
    • Medical
    • Dental
    • Life insurance
    • Accidental death and dismemberment insurance
    • Long-term disability insurance
    • Medical Flexible Spending Arrangement (FSA) or Limited Purpose FSA
    • Dependent Care Assistance Program (DCAP)

Instructions: Submit the PEBB Employee Request for Review/Notice of Appeal form to your payroll or benefits office.

Deadline: Your payroll or benefits office must receive the form no later than 30 calendar days after the date of the initial denial notice or decision you are appealing.

You disagree with a review decision made by your employer and are now requesting the PEBB Appeals Unit review of your employer's decision.

Instructions: Complete Section 7 of the PEBB Employee Request for Review/Notice of Appeal form and submit it to the PEBB Appeals Unit as directed on the form, or follow these appeal rules.

Deadline: The PEBB Appeals Unit must receive the form no later than 30 calendar days after the date of your employer's decision.

You disagree with a decision from the PEBB Program about:

  • Eligibility and enrollment in:
    • A premium payment plan
    • Medical Flexible Spending Arrangement (FSA) or Limited Purpose FSA
    • Dependent Care Assistance Program (DCAP)
    • Life insurance
  • Eligibility to participate in SmartHealth or receive a wellness incentive
  • Eligibility and enrollment for a dependent, extended dependent, or dependent child with a disability
  • Premium surcharges
  • Premium payments
Instructions: Follow the instructions on the decision letter you received from the PEBB Program.
Current or former employer group employee (or their dependent) of:
  • A county
  • A municipality
  • A political subdivision
  • A tribal government
  • An educational service district
  • The Washington Health Benefits Exchange
  • An employee organization representing state civil service employees
If your situation is: Follow these instructions and submission deadlines:

You disagree with a decision made by your employer and you are requesting your employer's review about:

  • Premium surcharges
  • Eligibility for or enrollment in:
    • Medical coverage
    • Dental coverage
Instructions: Contact your employer for information on how to appeal its decision or action and the required deadline to appeal.

Disagree with a decision by your employer, a PEBB insurance carrier, or the PEBB Program about:

  • Eligibility for or enrollment in:
    • Life insurance
    • Accidental death and dismemberment insurance
    • Long-term disability insurance
  • Eligibility to participate in SmartHealth or receive a wellness incentive

Instructions: Complete Sections 1 through 3 of the PEBB Employee Request for Review/Notice of Appeal form and submit to the PEBB Appeals Unit as directed on the form, or follow these appeal rules.

Deadline: The PEBB Appeals Unit must receive the form no later than 30 calendar days after the date of the denial notice or decision you are appealing

Retiree/PEBB Continuation Coverage subscriber, including:
  • An applicant for PEBB retiree benefits
  • A retiree A subscriber under PEBB Continuation Coverage
  • An applicant for PEBB Continuation Coverage
  • A survivor of a deceased employee or retiree as described in WAC 182-12-265 or 182-12-180
  • A survivor of emergency service personnel killed in the line of duty as described in WAC 182-12-250
  • The dependent of one of the above
If your situation is: Follow these instructions and submission deadlines:

You disagree with a decision from the PEBB Program about:

Premium surcharges Premium payments Eligibility for benefits Enrollment Eligibility to participate in SmartHealth or receive a wellness incentive

Instructions: Submit the Retiree/PEBB Continuation Coverage Notice of Appeal form to the PEBB Appeals Unit as instructed on the form, or follow these appeal rules.

Deadline: The PEBB Appeals Unit must receive your appeal no later than 60 calendar days after the date of the denial notice or decision you are appealing

How do I file an appeal?

Based on the group you belong to above, follow the instructions and submission deadlines for that type of appeal.

How do I appeal a decision made by a Presiding Officer?

You can request review of the Presiding Officer’s Initial Order by following the instructions in the Initial Order's "How to request review of this Initial Order" section.

Once your request for review is received by the PEBB Appeals Unit, a decision will generally be mailed within 20 days. If you have questions call us at 1-800-351-6827.

Deadline: The PEBB Appeals Unit must receive your request for review no later than 21 calendar days after the service date of the Initial Order.

How do I appeal a decision made by a plan?

If you are seeking a review of a decision by a PEBB medical or dental plan, insurance carrier, or benefit administrator, contact the plan to request information on how to appeal its decision. For example, you would contact your health plan to appeal a denial of a medical claim.

How can I make sure my personal representative has access to my health information?

You must provide the PEBB Program with a copy of a valid power of attorney or a completed Authorization for Release of Information form naming your representative and authorizing him or her to access your medical records and exercise your rights under the federal Health Insurance Portability and Accountability Act (HIPAA) of 1996.

Contact

PEBB Appeals Unit
Phone:
1-800-351-6827
Fax: 1-360-763-4709

Mailing address:
PEBB Appeals Unit
Health Care Authority
PO Box 45504
Olympia, WA 98504-5504

The PEBB Program