File an appeal: SEBB

Who can appeal?

If you are a subscriber, dependent, or applicant for SEBB Program benefits, you may be able to file an appeal of a decision made by your employer or the SEBB Program. The rules for filing an appeal are in chapter 182-32 WAC.

If you want to appeal a decision by a SEBB Program health 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.

How do I appeal a decision?

If you or your dependent disagrees with a specific decision or denial, you or your dependent may file an appeal. You can find guidance on filing an appeal in WAC 182-32.

School employee

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 A premium payment plan Eligibility for or enrollment in: Medical coverage Dental coverage Vision coverage Life insurance Accidental death and dismemberment (AD&D) insurance Long-term disability (LTD) insurance Flexible Spending Arrangement (FSA) or Limited Purpose FSA Dependent Care Assistance Program (DCAP)	Instructions: Complete Sections 1 through 3 the School Employee Request for Review/Notice of Appeal to your payroll or benefits office. Deadline: Your employer must receive the form no later than 30 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 requesting a SEBB Appeals Unit review of your employer's decision.	Instructions: Complete Section 7 and sign and date Section 9 of the School Employee Request for Review/Notice of Appeal. Deadline: The SEBB Appeals Unit must receive the form no later than 30 days after the date of your employer's review decision. Address Health Care Authority Attn: SEBB Appeals Unit PO Box 45504 Olympia, WA 98504
You disagree with a decision from the SEBB Program about: Eligibility for or enrollment in: A premium payment plan Flexible Spending Arrangement (FSA) or Limited Purpose FSA Dependent Care Assistance Program (DCAP) Life insurance Accidental death and dismemberment insurance Long-term disability 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	Follow the appeal instructions on the decision letter you received from the SEBB Program.

SEBB Continuation Coverage subscriber

If you are:

• An applicant for SEBB insurance coverage
• A SEBB Continuation Coverage subscriber
• A dependent of the above

If your situation is:

Follow these instructions and submission deadlines:

Your appeal concerns a decision from the SEBB Program about: Eligibility for benefits Enrollment Premium payments Premium surcharges Eligibility to participate in SmartHealth or receive a wellness incentive

Instructions: Complete all sections of the SEBB Continuation Coverage Notice of Appeal to request a brief adjudicative proceeding. Submit the form to the SEBB Appeals Unit as directed on the form, or follow the appeal rules as outlined in WAC 182-32-2070. Deadline: The SEBB Appeals Unit must receive the form no later than 60 days after the date of the initial denial notice or decision you are appealing. Address Health Care Authority Attn: SEBB Appeals Unit PO Box 45504 Olympia, WA 98504

How do I appeal a decision made by a plan?

If you are seeking a review of a decision made by a SEBB Program medical, dental, or vision plan, insurance carrier, or benefit administrator, contact the plan to request information on how to appeal its decision. This includes a benefit or claim, completion of SmartHealth requirements or a request for a reasonable alternative to a SmartHealth requirement, and life insurance and AD&D insurance premium payments.

How do I appeal an Initial Order if I disagree with the Presiding Officer's decision?

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 SEBB Appeals Unit, a decision will generally be mailed within 20 days. If you have questions call us at 1-800-351-6827. 

What is a formal hearing?

Under certain circumstances a presiding officer or review officer may determine that a hearing is necessary to make a decision. When this happens the appellant will receive an order converting their appeal. Shortly after the conversion, the appellant should receive an order describing when the formal hearing will take place. For more information see WAC 182-32-3000.

Can I have someone represent me in this appeal?

You may choose to be represented by another person, except employees of the Health Care Authority (HCA) or HCA’s authorized agents. This can include a non-attorney representative or an attorney that you personally hire to represent you. If you hire an attorney to represent you, the attorney must file a written notice of appearance. Both a non-attorney representative and a licensed attorney must provide the SEBB Appeals Unit with a written consent signed by you, permitting release of the relevant protected health information to the representative of your choosing.