WAC 182-16-030
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Agency filings affecting this section
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How can an employee or an employee's dependent appeal a decision made by an employing agency about eligibility or enrollment in benefits?
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Any employee or employee's dependent aggrieved by a decision made by an employing agency with regard to public employee benefits eligibility or enrollment may appeal that decision to the employing agency.
| Note: | Eligibility decisions address whether an employee or an employee's dependent is entitled to insurance coverage, as described in PEBB rules and policies. Enrollment decisions address the application for PEBB benefits as described in PEBB rules and policies, including but not limited to the submission of proper documentation and meeting enrollment deadlines. |
The employing agency may only reverse eligibility or enrollment decisions based on circumstances that arose due to delays caused by the employing agency or error(s) made by the employing agency.
(1) Any employee or employee's dependent aggrieved by an eligibility or enrollment decision made by an employing agency may appeal the decision by submitting a written request for review to the employing agency. The employing agency must receive the request for review within thirty days of the date of the initial denial notice. The contents of the request for review are to be provided in accordance with WAC
182-16-040.
(a) Upon receiving the request for review, the employing agency shall make a complete review of the initial denial by one or more staff who did not take part in the initial denial. As part of the review, the employing agency may hold a formal meeting or hearing, but is not required to do so.
(b) The employing agency shall render a written decision within thirty days of receiving the request for review. The written decision shall be sent to the appellant.
(c) A copy of the employing agency's written decision shall be sent to the employing agency's administrator or designee and to the PEBB appeals manager. The employing agency's written decision shall become the employing agency's final decision effective fifteen days after the date it is rendered.
(2) Any employee or employee's dependent who disagrees with the employing agency's decision in response to a request for review, as described in subsection (1) of this section, may appeal that decision by submitting a notice of appeal to the PEBB appeals committee. The PEBB appeals manager must receive the notice of appeal within thirty days of the date of the employing agency's written decision on the request for review.
As well, any employee or employee's dependent may appeal a decision about premium payments by submitting a notice of appeal to the PEBB appeals committee. The PEBB appeals manager must receive the notice of appeal within thirty days of the date of the denial notice. The contents of the notice of appeal are to be provided in accordance with WAC
182-16-040.
(a) The PEBB appeals manager shall notify the appellant in writing when the notice of appeal has been received.
(b) The PEBB appeals committee shall render a written decision within thirty days of receiving the notice of appeal. The written decision shall be sent to the appellant.
(c) Any appellant who disagrees with the decision of the PEBB appeals committee may request an administrative hearing, as described in WAC
182-16-050.
[Statutory Authority: RCW 41.05.160. 08-20-128 (Order 08-03), § 182-16-030, filed 10/1/08, effective 1/1/09; 07-20-129 (Order 07-01), § 182-16-030, filed 10/3/07, effective 11/3/07; 97-21-128, § 182-16-030, filed 10/21/97, effective 11/21/97. Statutory Authority: RCW 41.05.010 and 34.05.250. 91-14-025, § 182-16-030, filed 6/25/91, effective 7/26/91.]