File an appeal: PEBB

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, dental, or vision 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.

Current or former 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 coverage Dental coverage Vision coverage Life insurance AD&D insurance LTD insurance Flexible Spending Arrangement (FSA) or Limited Purpose FSA Dependent Care Assistance Program (DCAP)	Instructions: Complete Sections 1 through 3 of the PEBB Employee Request for Review/Notice of Appeal form and submit it to your payroll or benefits office. Deadline: Your payroll or benefits office 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 now requesting the PEBB Appeals Unit review of your employer's decision.	Instructions: Complete Section 7 and sign and date Section 9 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 days after the date of your employer's written review decision date in Section 4.
You disagree with a decision from the PEBB Program about: Eligibility and enrollment in: A premium payment plan 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 PEBB participating 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 about: Premium surcharges Eligibility for or enrollment in PEBB health insurance coverage	Instructions: Contact your employer for information on how to appeal the decision or action.
Disagree with a decision by your employer, a PEBB insurance carrier, or contracted vendor: Eligibility for or enrollment in: Life insurance AD&D insurance LTD insurance PEBB health insurance coverage for a dependent, extended dependent, or dependent with a disability 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 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 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.

How do I appeal a decision made by a plan?

If you are seeking a review of a decision by a PEBB medical dental, or vision 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.