| Is it really an appeal? |
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From time to time, PEBB receives a member eligibility appeal stating the agency denied the member’s request, but the agency told the member to appeal the agency decision to PEBB. In some of these instances, the situation has no gray area, and it’s clear the agency decision was correct according to the PEBB rules. The member does have the appeal process; however, PEBB generally will not reverse the agency decision in areas that are clear.
Agencies could help by rephrasing the appeal information in these instances to direct the member to the rule. This saves time for the member time and PEBB.
Example: Joe marries Sally in June and submits his medical and dental update form to the agency in July. The agency enrolls Joe’s new wife in medical and dental with an effective date for coverage August 1. Sally gives birth in July to Joe’s son. Joe really wanted her coverage to start July 1 and asks the agency to make the enrollment effective that date. The agency tells Joe no, but suggests he appeal to PEBB. PEBB will deny the appeal based on the same rule that the Agency used when enrolling Sally. (Coverage is effective first of the month following the submission of forms to the agency after the event date)
Note that in this scenario Joe’s son receives coverage for the first 31 days after the birth even though mom was not covered. This is because the baby is Joe’s biological newborn. Joe needs to remember to submit update forms within 60 days of the birth to continue coverage for his son beyond the first 31 days of coverage.
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