Chapter 182-16 WAC

Last Update: 8/20/19

APPEALS PRACTICE AND PROCEDURE

WAC Sections

PART I
GENERAL PROVISIONS
182-16-010Purpose.
182-16-020Definitions.
182-16-055Mailing address changes.
182-16-058Service or serve.
182-16-064Applicable rules and laws.
182-16-066Burden of proof, standard of proof, and presumptions.
182-16-120Computation of time.
182-16-130Index of significant decisions.
PART II
BRIEF ADJUDICATIVE PROCEEDINGS
182-16-2000Brief adjudicative proceedings.
182-16-2005Record—Brief adjudicative proceeding.
182-16-2010Appealing a decision regarding public employees benefits board (PEBB) eligibility, enrollment, premium payments, premium surcharges, a wellness incentive, or the administration of benefits.
182-16-2020Appealing a decision made by a state agency about eligibility, premium surcharges, or enrollment in benefits.
182-16-2030Appealing a public employees benefits board (PEBB) program decision regarding eligibility, enrollment, premium payments, premium surcharges, a PEBB wellness incentive, or certain decisions made by an employer group.
182-16-2040How can a subscriber appeal a decision regarding the administration of wellness incentive program requirements?
182-16-2050How can an employee appeal a decision regarding the administration of benefits offered under the salary reduction plan?
182-16-2060How can an entity or organization appeal a decision of the health care authority to deny an employer group application?
182-16-2070What should a written request for administrative review and a request for brief adjudicative proceeding contain?
182-16-2080Who can appeal or represent a party in a brief adjudicative proceeding?
182-16-2085Continuances.
182-16-2090Initial order.
182-16-2100How to request a review of an initial order resulting from a brief adjudicative proceeding.
182-16-2105Withdrawing the request for a brief adjudicative proceeding or review of an initial order.
182-16-2110Final order.
182-16-2120Request for reconsideration.
182-16-2130Judicial review of final order.
182-16-2140Presiding officer—Designation and authority.
182-16-2150Review officer or officers—Designation and authority.
182-16-2160Conversion of a brief adjudicative proceeding to a formal administrative hearing.
PART III
FORMAL ADMINISTRATIVE HEARINGS
182-16-3000Formal administrative hearings.
182-16-3005Record—Formal administrative hearings.
182-16-3010Requirements to appear and represent a party in the formal administrative hearing process.
182-16-3015Hearing officers—Assignment, motions of prejudice, and disqualification.
182-16-3030Authority of the hearing officer.
182-16-3080Time requirements for service of notices made by the hearing officer.
182-16-3090Formal administrative hearing location.
182-16-3100Rescheduling and continuances for formal administrative hearings.
182-16-3110Prehearing conferences.
182-16-3120Dispositive motions.
182-16-3130Subpoenas.
182-16-3140Orders of dismissal—Reinstating a formal administrative hearing after an order of dismissal.
182-16-3160Withdrawing a formal administrative hearing.
182-16-3170Final order deadline—Required information.
182-16-3180Request for reconsideration and response—Process.
182-16-3190Decisions on requests for reconsideration.
182-16-3200Judicial review of final order.
DISPOSITION OF SECTIONS FORMERLY CODIFIED IN THIS TITLE
182-16-025Where do members appeal decisions regarding eligibility, enrollment, premium payments, premium surcharges, a public employees benefits board (PEBB) wellness incentive, or the administration of benefits? [Statutory Authority: RCW 41.05.021, 41.05.160 and PEBB policy resolutions. WSR 17-19-077 (Order 2017-01), § 182-16-025, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-025, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-025, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160, 2013 2nd sp.s. c 4 and PEBB policy resolutions. WSR 14-08-040, § 182-16-025, filed 3/26/14, effective 4/26/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-16-025, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-16-025, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-16-025, filed 10/6/10, effective 1/1/11.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-030How can a current or former employee or an employee's dependent appeal a decision made by a state agency about eligibility, premium surcharge, or enrollment in benefits? [Statutory Authority: RCW 41.05.021, 41.05.160 and PEBB policy resolutions. WSR 17-19-077 (Order 2017-01), § 182-16-030, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-030, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-030, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160, 2013 2nd sp.s. c 4 and PEBB policy resolutions. WSR 14-08-040, § 182-16-030, filed 3/26/14, effective 4/26/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-16-030, filed 9/25/12, effective 11/1/12; WSR 10-20-147 (Order 10-02), § 182-16-030, filed 10/6/10, effective 1/1/11; WSR 09-23-102 (Order 09-02), § 182-16-030, filed 11/17/09, effective 1/1/10; WSR 08-20-128 (Order 08-03), § 182-16-030, filed 10/1/08, effective 1/1/09; WSR 07-20-129 (Order 07-01), § 182-16-030, filed 10/3/07, effective 11/3/07; WSR 97-21-128, § 182-16-030, filed 10/21/97, effective 11/21/97. Statutory Authority: RCW 41.05.010 and 34.05.250. WSR 91-14-025, § 182-16-030, filed 6/25/91, effective 7/26/91.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-032How can a decision made by the public employees benefits board (PEBB) program regarding eligibility, enrollment, premium payments, premium surcharge, eligibility to participate in the PEBB wellness incentive program or receive a PEBB wellness incentive; or a decision made by an employer group regarding life insurance or LTD insurance be appealed? [Statutory Authority: RCW 41.05.021, 41.05.160 and PEBB policy resolutions. WSR 17-19-077 (Order 2017-01), § 182-16-032, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-032, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160, 2013 2nd sp.s. c 4 and PEBB policy resolutions. WSR 14-08-040, § 182-16-032, filed 3/26/14, effective 4/26/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-16-032, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-16-032, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-16-032, filed 10/6/10, effective 1/1/11; WSR 09-23-102 (Order 09-02), § 182-16-032, filed 11/17/09, effective 1/1/10; WSR 08-20-128 (Order 08-03), § 182-16-032, filed 10/1/08, effective 1/1/09.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-034How can a PEBB enrollee appeal a decision regarding the administration of a PEBB medical plan, insured dental plan, life insurance, long-term care insurance, long-term disability insurance, or property or casualty insurance? [Statutory Authority: RCW 41.05.160. WSR 09-23-102 (Order 09-02), § 182-16-034, filed 11/17/09, effective 1/1/10; WSR 08-20-128 (Order 08-03), § 182-16-034, filed 10/1/08, effective 1/1/09.] Repealed by WSR 10-20-147 (Order 10-02), filed 10/6/10, effective 1/1/11. Statutory Authority: RCW 41.05.160.
182-16-035How can a subscriber appeal a decision regarding the administration of wellness incentive program requirements? [Statutory Authority: RCW 41.05.021, 41.05.160 and PEBB policy resolutions. WSR 17-19-077 (Order 2017-01), § 182-16-035, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-035, filed 9/25/14, effective 1/1/15.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-036How can an employee who is eligible to participate in the state's salary reduction plan appeal a decision regarding the administration of benefits offered under the state's salary reduction plan? [Statutory Authority: RCW 41.05.021, 41.05.160 and PEBB policy resolutions. WSR 17-19-077 (Order 2017-01), § 182-16-036, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-16-036, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-036, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-16-036, filed 9/25/12, effective 11/1/12; WSR 09-23-102 (Order 09-02), § 182-16-036, filed 11/17/09, effective 1/1/10; WSR 08-20-128 (Order 08-03), § 182-16-036, filed 10/1/08, effective 1/1/09.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-037How can an enrollee appeal a decision by the agency's self-insured dental plan? [Statutory Authority: RCW 41.05.160. WSR 09-23-102 (Order 09-02), § 182-16-037, filed 11/17/09, effective 1/1/10; WSR 08-20-128 (Order 08-03), § 182-16-037, filed 10/1/08, effective 1/1/09.] Repealed by WSR 10-20-147 (Order 10-02), filed 10/6/10, effective 1/1/11. Statutory Authority: RCW 41.05.160.
182-16-038How can an entity or organization appeal a decision of the health care authority to deny an employer group application? [Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-038, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-038, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-16-038, filed 9/25/12, effective 11/1/12; WSR 08-20-128 (Order 08-03), § 182-16-038, filed 10/1/08, effective 1/1/09.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-040What should the request for review or notice of appeal contain? [Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-040, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (Admin # 2015-01 Rev 1), § 182-16-040, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160. WSR 08-20-128 (Order 08-03), § 182-16-040, filed 10/1/08, effective 1/1/09; WSR 07-20-129 (Order 07-01), § 182-16-040, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. WSR 05-16-046 (Order 05-01), § 182-16-040, filed 7/27/05, effective 8/27/05. Statutory Authority: RCW 41.05.160. WSR 97-21-128, § 182-16-040, filed 10/21/97, effective 11/21/97. Statutory Authority: RCW 41.05.010 and 34.05.250. WSR 91-14-025, § 182-16-040, filed 6/25/91, effective 7/26/91.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-050How can an appellant aggrieved by a written decision made by the public employees benefits board (PEBB) appeals committee request an administrative hearing? [Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-050, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-050, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-16-050, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-16-050, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 10-20-147 (Order 10-02), § 182-16-050, filed 10/6/10, effective 1/1/11; WSR 08-20-128 (Order 08-03), § 182-16-050, filed 10/1/08, effective 1/1/09; WSR 07-20-129 (Order 07-01), § 182-16-050, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.160, 41.05.350, and 41.05.165. WSR 05-16-046 (Order 05-01), § 182-16-050, filed 7/27/05, effective 8/27/05. Statutory Authority: RCW 41.05.160. WSR 97-21-128, § 182-16-050, filed 10/21/97, effective 11/21/97. Statutory Authority: RCW 41.05.010 and 34.05.250. WSR 91-14-025, § 182-16-050, filed 6/25/91, effective 7/26/91.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-052Requirements to appear and represent a party in the administrative hearing process. [Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-052, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-052, filed 9/25/14, effective 1/1/15.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-060Index of significant decisions. [Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-16-060, filed 9/25/12, effective 11/1/12.] Repealed by WSR 14-20-058 (PEBB Admin 2014-02), filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4.
182-16-061Presiding officers—Assignment, motions of prejudice, and disqualification. [Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-061, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-061, filed 9/25/14, effective 1/1/15.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-062Authority of the presiding officer. [Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-062, filed 9/25/14, effective 1/1/15.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-067Service of documents on another party. [Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-067, filed 10/4/16, effective 1/1/17.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-070Calculating when a hearing deadline ends. [Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-070, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-070, filed 9/25/14, effective 1/1/15.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-071Time requirements for service of notices made by the presiding officer. [Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-071, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-071, filed 9/25/14, effective 1/1/15.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-072Hearing location. [Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-072, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-072, filed 9/25/14, effective 1/1/15.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-073Rescheduling and continuances. [Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-073, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-16-073, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-073, filed 9/25/14, effective 1/1/15.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-080Determining if an administrative hearing right exists. [Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-080, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-16-080, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-080, filed 9/25/14, effective 1/1/15.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-081Prehearing conferences. [Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-081, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-081, filed 9/25/14, effective 1/1/15.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-082Dispositive motions. [Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-082, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-082, filed 9/25/14, effective 1/1/15.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-085Subpoenas. [Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-085, filed 10/4/16, effective 1/1/17.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-090Orders of dismissal—Reinstating a hearing after an order of dismissal. [Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-090, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-090, filed 9/25/14, effective 1/1/15.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-091Settlement agreements. [Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-091, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-091, filed 9/25/14, effective 1/1/15.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-092Withdrawing the request for an administrative hearing. [Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-092, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-092, filed 9/25/14, effective 1/1/15.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-100Final order deadline—Required information. [Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-100, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-100, filed 9/25/14, effective 1/1/15.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-105Motion for reconsideration and response—Process. [Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-105, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-105, filed 9/25/14, effective 1/1/15.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-106Decisions on motions for reconsideration. [Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-106, filed 9/25/14, effective 1/1/15.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.
182-16-110Judicial review of final order. [Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-110, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-110, filed 9/25/14, effective 1/1/15.] Repealed by WSR 18-22-033 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 41.05.160.


(Effective until January 1, 2020)

182-16-010
Purpose.

This chapter describes the general rules and procedures that apply to the authority's brief adjudicative proceedings and formal administrative hearings.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-010, filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and PEBB policy resolutions. WSR 17-19-077 (Order 2017-01), § 182-16-010, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-010, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-010, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-16-010, filed 9/25/12, effective 11/1/12; WSR 08-20-128 (Order 08-03), § 182-16-010, filed 10/1/08, effective 1/1/09. Statutory Authority: RCW 41.05.010 and 34.05.250. WSR 91-14-025, § 182-16-010, filed 6/25/91, effective 7/26/91.]
(Effective January 1, 2020)

182-16-010

Purpose.

This chapter describes the general rules and procedures that apply to the health care authority's brief adjudicative proceedings and formal administrative hearings for the public employees benefits board program.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-010, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-010, filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and PEBB policy resolutions. WSR 17-19-077 (Order 2017-01), § 182-16-010, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-010, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-010, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-16-010, filed 9/25/12, effective 11/1/12; WSR 08-20-128 (Order 08-03), § 182-16-010, filed 10/1/08, effective 1/1/09. Statutory Authority: RCW 41.05.010 and 34.05.250. WSR 91-14-025, § 182-16-010, filed 6/25/91, effective 7/26/91.]



(Effective until January 1, 2020)

182-16-020
Definitions.

The following definitions apply throughout this chapter unless the context clearly indicates another meaning:
"Appellant" means a person or entity who requests a review by the PEBB appeals unit or a formal administrative hearing about the action of the HCA or its contracted vendor.
"Authority" or "HCA" means the Washington state health care authority.
"Brief adjudicative proceeding" means the process described in RCW 34.05.482 through 34.05.494.
"Business days" means all days except Saturdays, Sundays, and all legal holidays as set forth in RCW 1.16.050.
"Calendar days" or "days" means all days including Saturdays and Sundays.
"Continuance" means a change in the date or time of when a brief adjudicative proceeding or formal administrative hearing will occur.
"Contracted vendor" means any person, persons, or entity under contract or agreement with the HCA to provide goods or services for the provision or administration of PEBB benefits. The term "contracted vendor" includes subcontractors of the HCA and subcontractors of any person, persons, or entity under contract or agreement with the HCA that provide goods or services for the provision or administration of PEBB benefits.
"Denial" or "denial notice" means an action by, or communication from, either an employing agency, or the PEBB program that aggrieves a subscriber, a dependent, or an applicant, with regard to PEBB benefits including, but not limited to, actions or communications expressly designated as a "denial," "denial notice," or "cancellation notice."
"Dependent" means a person who meets eligibility requirements in WAC 182-12-260, except that "surviving spouses, state registered domestic partners, and dependent children" of emergency service personnel who are killed in the line of duty is defined in WAC 182-12-250.
"Dependent care assistance program" or "DCAP" means a benefit plan whereby state and public employees may pay for certain employment related dependent care with pretax dollars as provided in the salary reduction plan under this chapter pursuant to 26 U.S.C. Sec. 129 or other sections of the Internal Revenue Code.
"Director" means the director of the authority.
"Documents" means papers, letters, writings, electronic mail, electronic files, or other printed or written items.
"Employee" for the public employees benefits board program includes all employees of the state, whether or not covered by civil service; elected and appointed officials of the executive branch of government, including full-time members of boards, commissions, or committees; justices of the supreme court and judges of the court of appeals and the superior courts; and members of the state legislature. Pursuant to contractual agreement with the authority, "employee" may also include: (a) Employees of a county, municipality, or other political subdivision of the state and members of the legislative authority of any county, city, or town who are elected to office after February 20, 1970, if the legislative authority of the county, municipality, or other political subdivision of the state submits application materials to the authority to provide any of its insurance programs by contract with the authority, as provided in RCW 41.04.205 and 41.05.021 (1)(g); (b) employees of employee organizations representing state civil service employees, at the option of each such employee organization, and, effective October 1, 1995, employees of employee organizations currently pooled with employees of school districts for the purpose of purchasing insurance benefits, at the option of each such employee organization; (c) employees of a school district if the authority agrees to provide any of the school districts' insurance programs by contract with the authority as provided in RCW 28A.400.350; (d) employees of a tribal government, if the governing body of the tribal government seeks and receives the approval of the authority to provide any of its insurance programs by contract with the authority, as provided in RCW 41.05.021 (1)(f) and (g); (e) employees of the Washington health benefit exchange if the governing board of the exchange established in RCW 43.71.020 seeks and receives approval of the authority to provide any of its insurance programs by contract with the authority, as provided in RCW 41.05.021 (1)(g) and (n); and (f) employees of a charter school established under chapter 28A.710 RCW. "Employee" does not include: Adult family home providers; unpaid volunteers; patients of state hospitals; inmates; employees of the Washington state convention and trade center as provided in RCW 41.05.110; students of institutions of higher education as determined by their institution; and any others not expressly defined as employees under RCW 41.05.011 or by the authority under this chapter.
"Employer-based group medical" means group medical related to a current employment relationship. It does not include medical coverage available to retired employees, individual market medical coverage, or government-sponsored programs such as medicare or medicaid.
"Employer group" means those counties, municipalities, political subdivisions, the Washington health benefit exchange, tribal governments, school districts, educational service districts, and employee organizations representing state civil service employees, obtaining employee benefits through a contractual agreement with the authority as described in WAC 182-08-245.
"Employing agency" for the public employees benefits board program means a division, department, or separate agency of state government, including an institution of higher education; a county, municipality, school district, educational service district, or other political subdivision; and a tribal government covered by chapter 41.05 RCW.
"Enrollee" means a person who meets all eligibility requirements defined in chapter 182-12 WAC, who is enrolled in PEBB benefits, and for whom applicable premium payments have been made.
"File" or "filing" means the act of delivering documents to the office of the presiding officer, review officer, or hearing officer. A document is considered filed when it is received by the authority or its designee.
"Final order" means an order that is the final PEBB program decision.
"Formal administrative hearing" means a proceeding before a hearing officer that gives an appellant an opportunity for an evidentiary hearing.
"HCA hearing representative" means a person who is authorized to represent the PEBB program in a formal administrative hearing. The person may be an assistant attorney general or authorized HCA employee.
"Health plan" means a plan offering medical or dental, or both, developed by the public employees benefits board and provided by a contracted vendor or self-insured plans administered by the HCA.
"Hearing officer" means an impartial decision maker who presides at a formal administrative hearing, and is:
• A director-designated HCA employee; or
• When the director has designated the office of administrative hearings (OAH) as a hearing body, an administrative law judge employed by the OAH.
"Institutions of higher education" means the state public research universities, the public regional universities, The Evergreen State College, the community and technical colleges, and the state board for community and technical colleges.
"Life insurance" for eligible employees includes basic life insurance and accidental death and dismemberment (AD&D) insurance paid for by the employing agency, as well as optional life insurance and optional AD&D insurance offered to and paid for by employees for themselves and their dependents. Life insurance for eligible retirees includes retiree term life insurance offered to and paid for by retirees.
"LTD insurance" includes basic long-term disability insurance paid for by the employing agency and long-term disability insurance offered to employees on an optional basis.
"Medical flexible spending arrangement" or "medical FSA" means a benefit plan whereby eligible state and public employees may reduce their salary before taxes to pay for medical expenses not reimbursed by insurance as provided in the salary reduction plan under this chapter pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.
"PEBB" means the public employees benefits board.
"PEBB benefits" means one or more insurance coverages or other employee benefits administered by the PEBB program within the health care authority.
"PEBB insurance coverage" means any health plan, life insurance, long-term disability (LTD) insurance, long-term care insurance, or property and casualty insurance administered as a PEBB benefit.
"PEBB program" means the program within the HCA that administers insurance and other benefits for eligible employees (as described in WAC 182-12-114), eligible retired employees (as described in WAC 182-12-171 and 182-12-180), eligible survivors (as described in WAC 182-12-180, 182-12-250, and 182-12-265), eligible dependents (as described in WAC 182-12-250 and 182-12-260), and others as defined in RCW 41.05.011.
"Prehearing conference" means a proceeding scheduled and conducted by a hearing officer to address issues in preparation for a formal administrative hearing.
"Premium payment plan" means a benefit plan whereby state and public employees may pay their share of group health plan premiums with pretax dollars as provided in the salary reduction plan.
"Premium surcharge" means a payment required from a subscriber, in addition to the subscriber's medical premium contribution, due to an enrollee's tobacco use or an enrolled subscriber's spouse or state registered domestic partner choosing not to enroll in their employer-based group medical when:
• The spouse's or state registered domestic partner's share of the medical premiums is less than ninety-five percent of the additional cost an employee would be required to pay to enroll a spouse or state registered domestic partner in the Uniform Medical Plan (UMP) Classic; and
• The benefits have an actuarial value of at least ninety-five percent of the actuarial value of UMP Classic benefits.
"Presiding officer" means an impartial decision maker who conducts a brief adjudicative proceeding and is a director-designated HCA employee.
"Review officer or officers" means one or more delegates from the director that consider appeals relating to the administration of PEBB benefits by the PEBB program.
"Salary reduction plan" means a benefit plan whereby state and public employees may agree to a reduction of salary on a pretax basis to participate in the dependent care assistance program (DCAP), medical flexible spending arrangement (FSA), or premium payment plan offered pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.
"Service" or "serve" means the process described in WAC 182-16-058.
"State agency" means an office, department, board, commission, institution, or other separate unit or division, however designated, of the state government, and all personnel thereof. It includes the legislature, executive branch, and agencies or courts within the judicial branch, as well as institutions of higher education, and any unit of state government established by law.
"Subscriber" means the employee, retiree, continuation coverage enrollee, or survivor who has been determined eligible by the PEBB program, employer group, state agency, or charter school and is the individual to whom the PEBB program and contracted vendors will issue all notices, information, requests, and premium bills on behalf of enrollees.
"Tobacco products" means any product made with or derived from tobacco that is intended for human consumption, including any component, part, or accessory of a tobacco product. This includes, but is not limited to, cigars, cigarettes, pipe tobacco, chewing tobacco, snuff, and other tobacco products. It does not include e-cigarettes or United States Food and Drug Administration (FDA) approved quit aids.
"Tobacco use" means any use of tobacco products within the past two months. Tobacco use, however, does not include the religious or ceremonial use of tobacco.
"Tribal government" means an Indian tribal government as defined in Section 3(32) of the Employee Retirement Income Security Act of 1974 (ERISA), as amended, or an agency or instrumentality of the tribal government, that has government offices principally located in this state.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-020, filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and PEBB policy resolutions. WSR 17-19-077 (Order 2017-01), § 182-16-020, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-020, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-16-020, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-020, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160, 2013 2nd sp.s. c 4 and PEBB policy resolutions. WSR 14-08-040, § 182-16-020, filed 3/26/14, effective 4/26/14. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-16-020, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-16-020, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-16-020, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 09-23-102 (Order 09-02), § 182-16-020, filed 11/17/09, effective 1/1/10; WSR 08-20-128 (Order 08-03), § 182-16-020, filed 10/1/08, effective 1/1/09; WSR 07-20-129 (Order 07-01), § 182-16-020, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.010 and 34.05.250. WSR 91-14-025, § 182-16-020, filed 6/25/91, effective 7/26/91.]
(Effective January 1, 2020)

182-16-020

Definitions.

The following definitions apply throughout this chapter unless the context clearly indicates another meaning:
"Accidental death and dismemberment insurance" or "AD&D" means basic accidental death and dismemberment (AD&D) insurance paid for by the employing agency, as well as supplemental accidental death and dismemberment insurance offered to and paid for by employees for themselves and their dependents.
"Appellant" means a person who requests a brief adjudicative proceeding with the PEBB appeals unit about the action of the employing agency, the HCA, or its contracted vendor.
"Authority" or "HCA" means the Washington state health care authority.
"Brief adjudicative proceeding" means the process described in RCW 34.05.482 through 34.05.494 and in WAC 182-16-2000 through 182-16-2160.
"Business days" means all days except Saturdays, Sundays, and all legal holidays as set forth in RCW 1.16.050.
"Calendar days" or "days" means all days including Saturdays, Sundays, and all legal state holidays as set forth in RCW 1.16.050.
"Continuance" means a change in the date or time of when a brief adjudicative proceeding or formal administrative hearing will occur.
"Contracted vendor" means any person, persons, or entity under contract or agreement with the HCA to provide goods or services for the provision or administration of PEBB benefits. The term "contracted vendor" includes subcontractors of the HCA and subcontractors of any person, persons, or entity under contract or agreement with the HCA that provide goods or services for the provision or administration of PEBB benefits.
"Denial" or "denial notice" means an action by, or communication from, an employing agency, contracted vendor, or the PEBB program that aggrieves a subscriber, a dependent, or an applicant, with regard to PEBB benefits including, but not limited to, actions or communications expressly designated as a "denial," "denial notice," or "cancellation notice."
"Dependent" means a person who meets eligibility requirements in WAC 182-12-260, except that "surviving spouses, state registered domestic partners, and dependent children" of emergency service personnel who are killed in the line of duty is defined in WAC 182-12-250.
"Dependent care assistance program" or "DCAP" means a benefit plan whereby state employees may pay for certain employment related dependent care with pretax dollars as provided in the salary reduction plan under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 129 or other sections of the Internal Revenue Code.
"Director" means the director of the authority.
"Dispositive motion" means a motion made to a presiding officer, review officer, or hearing officer to decide a claim or case in favor of the moving party without further proceedings.
"Documents" means papers, letters, writings, electronic mail, electronic files, or other printed or written items.
"Employee" for the public employees benefits board program includes all employees of the state, whether or not covered by civil service; elected and appointed officials of the executive branch of government, including full-time members of boards, commissions, or committees; justices of the supreme court and judges of the court of appeals and the superior courts; and members of the state legislature. Pursuant to contractual agreement with the authority, "employee" may also include: (a) Employees of a county, municipality, or other political subdivision of the state and members of the legislative authority of any county, city, or town who are elected to office after February 20, 1970, if the legislative authority of the county, municipality, or other political subdivision of the state submits application materials to the authority to provide any of its insurance programs by contract with the authority, as provided in RCW 41.04.205 and 41.05.021 (1)(g); (b) employees of employee organizations representing state civil service employees, at the option of each such employee organization; (c) through December 31, 2019, employees of a school district or represented employees of an educational service district if the authority agrees to provide any of the school districts' or educational service districts' insurance programs by contract with the authority as provided in RCW 28A.400.350; (d) employees of a tribal government, if the governing body of the tribal government seeks and receives the approval of the authority to provide any of its insurance programs by contract with the authority, as provided in RCW 41.05.021 (1)(f) and (g); (e) employees of the Washington health benefit exchange if the governing board of the exchange established in RCW 43.71.020 seeks and receives approval of the authority to provide any of its insurance programs by contract with the authority, as provided in RCW 41.05.021 (1)(g) and (n); (f) through December 31, 2019, employees of a charter school established under chapter 28A.710 RCW; and (g) through December 31, 2023, nonrepresented employees of an educational service district. "Employee" does not include: Adult family home providers; unpaid volunteers; patients of state hospitals; inmates; employees of the Washington state convention and trade center as provided in RCW 41.05.110; students of institutions of higher education as determined by their institution; and any others not expressly defined as employees under RCW 41.05.011 or by the authority under this chapter.
"Employer-based group medical" means group medical related to a current employment relationship. It does not include medical coverage available to retired employees, individual market medical coverage, or government-sponsored programs such as medicare or medicaid.
"Employer group" means those counties, municipalities, political subdivisions, the Washington health benefit exchange, tribal governments, employee organizations representing state civil service employees, and through December 31, 2019, school districts and charter schools, and through December 31, 2023, educational service districts obtaining employee benefits through a contractual agreement with the authority to participate in benefit plans developed by the public employees benefits board as described in WAC 182-08-245.
"Employing agency" for the public employees benefits board program means a division, department, or separate agency of state government, including an institution of higher education; a county, municipality, or other political subdivision; and a tribal government covered by chapter 41.05 RCW.
"Enrollee" means a person who meets all eligibility requirements defined in chapter 182-12 WAC, who is enrolled in PEBB benefits, and for whom applicable premium payments have been made.
"File" or "filing" means the act of delivering documents to the office of the presiding officer, review officer, or hearing officer. A document is considered filed when it is received by the authority or its designee.
"Final order" means an order that is the final health care authority decision.
"Formal administrative hearing" means a proceeding before a hearing officer that gives an appellant an opportunity for an evidentiary hearing as described in RCW 34.05.413 through 34.05.476 and WAC 182-16-3000 through 182-16-3200.
"HCA hearing representative" means a person who is authorized to represent the PEBB program in a formal administrative hearing. The person may be an assistant attorney general or authorized HCA employee.
"Health plan" means a plan offering medical or dental, or both, developed by the PEBB and provided by a contracted vendor or self-insured plans administered by the HCA.
"Hearing officer" means an impartial decision maker who presides at a formal administrative hearing, and is:
• A director-designated HCA employee; or
• When the director has designated the office of administrative hearings (OAH) as a hearing body, an administrative law judge employed by the OAH.
"Institutions of higher education" means the state public research universities, the public regional universities, The Evergreen State College, the community and technical colleges, and the state board for community and technical colleges.
"Life insurance" means basic life insurance paid for by the employing agency, as well as supplemental life insurance offered to and paid for by employees for themselves and their dependents. Life insurance for eligible retirees includes retiree term life insurance offered to and paid for by retirees.
"Long-term disability insurance" or "LTD insurance" means basic long-term disability insurance paid for by the employing agency and supplemental long-term disability insurance offered to and paid for by the employee.
"Medical flexible spending arrangement" or "medical FSA" means a benefit plan whereby eligible state employees may reduce their salary before taxes to pay for medical expenses not reimbursed by insurance as provided in the salary reduction plan established under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.
"PEBB" means the public employees benefits board.
"PEBB benefits" means one or more insurance coverages or other employee benefits administered by the PEBB program within the health care authority.
"PEBB insurance coverage" means any health plan, life insurance, accidental death and dismemberment insurance, long-term disability (LTD) insurance, long-term care insurance, or property and casualty insurance administered as a PEBB benefit.
"PEBB program" means the program within the HCA that administers insurance and other benefits for eligible employees (as described in WAC 182-12-114), eligible retired employees (as described in WAC 182-12-171 and 182-12-180), eligible survivors (as described in WAC 182-12-180, 182-12-250, and 182-12-265), eligible dependents (as described in WAC 182-12-250 and 182-12-260), and others as defined in RCW 41.05.011.
"Prehearing conference" means a proceeding scheduled and conducted by a hearing officer to address issues in preparation for a formal administrative hearing.
"Premium payment plan" means a benefit plan whereby public employees may pay their share of group health plan premiums with pretax dollars as provided in the salary reduction plan under chapter 41.05 RCW pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.
"Premium surcharge" means a payment required from a subscriber, in addition to the subscriber's medical premium contribution, due to an enrollee's tobacco use or an enrolled subscriber's spouse or state registered domestic partner choosing not to enroll in their employer-based group medical when:
• The spouse's or state registered domestic partner's share of the medical premiums is less than ninety-five percent of the additional cost an employee would be required to pay to enroll a spouse or state registered domestic partner in the public employees benefits board (PEBB) Uniform Medical Plan (UMP) Classic; and
• The benefits have an actuarial value of at least ninety-five percent of the actuarial value of PEBB UMP Classic benefits.
"Presiding officer" means an impartial decision maker who conducts a brief adjudicative proceeding and is a director-designated HCA employee.
"Public employee" has the same meaning as employee.
"Review officer or officers" means one or more delegates from the director that consider appeals relating to the administration of PEBB benefits by the PEBB program.
"Salary reduction plan" means a benefit plan whereby public employees may agree to a reduction of salary on a pretax basis to participate in the dependent care assistance program, medical flexible spending arrangement, or premium payment plan offered pursuant to 26 U.S.C. Sec. 125 or other sections of the Internal Revenue Code.
"Service" or "serve" means the process described in WAC 182-16-058.
"State agency" means an office, department, board, commission, institution, or other separate unit or division, however designated, of the state government. It includes the legislature, executive branch, and agencies or courts within the judicial branch, as well as institutions of higher education, and any unit of state government established by law.
"State registered domestic partner" has the same meaning as defined in RCW 26.60.020(1) and substantially equivalent legal unions from other jurisdictions as defined in RCW 26.60.090.
"Subscriber" means the employee, retiree, continuation coverage enrollee, or survivor who has been determined eligible by the PEBB program, employer group, or state agency, is enrolled in PEBB benefits, and is the individual to whom the PEBB program and contracted vendors will issue all notices, information, requests, and premium bills on behalf of an enrollee.
"Tobacco products" means any product made with or derived from tobacco that is intended for human consumption, including any component, part, or accessory of a tobacco product. This includes, but is not limited to, cigars, cigarettes, pipe tobacco, chewing tobacco, snuff, and other tobacco products. It does not include e-cigarettes or United States Food and Drug Administration (FDA) approved quit aids.
"Tobacco use" means any use of tobacco products within the past two months. Tobacco use, however, does not include the religious or ceremonial use of tobacco.
"Tribal government" means an Indian tribal government as defined in Section 3(32) of the Employee Retirement Income Security Act of 1974 (ERISA), as amended, or an agency or instrumentality of the tribal government, that has government offices principally located in this state.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-020, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-020, filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160 and PEBB policy resolutions. WSR 17-19-077 (Order 2017-01), § 182-16-020, filed 9/15/17, effective 1/1/18. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-020, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160, 2015 c 116, and PEBB policy resolutions. WSR 15-22-099 (PEBB Admin # 2015-01 Rev 1), § 182-16-020, filed 11/4/15, effective 1/1/16. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-020, filed 9/25/14, effective 1/1/15. Statutory Authority: RCW 41.05.160, 2013 2nd sp.s. c 4 and PEBB policy resolutions. WSR 14-08-040, § 182-16-020, filed 3/26/14, effective 4/26/14. Statutory Authority: RCW 41.05.160 and 2012 2nd sp.s. c 3. WSR 13-22-019 (Admin. 2013-01), § 182-16-020, filed 10/28/13, effective 1/1/14. Statutory Authority: RCW 41.05.160. WSR 12-20-022 (Order 2012-01), § 182-16-020, filed 9/25/12, effective 11/1/12. Statutory Authority: RCW 41.05.160 and 2011 c 8. WSR 11-22-036 (Order 11-02), § 182-16-020, filed 10/26/11, effective 1/1/12. Statutory Authority: RCW 41.05.160. WSR 09-23-102 (Order 09-02), § 182-16-020, filed 11/17/09, effective 1/1/10; WSR 08-20-128 (Order 08-03), § 182-16-020, filed 10/1/08, effective 1/1/09; WSR 07-20-129 (Order 07-01), § 182-16-020, filed 10/3/07, effective 11/3/07. Statutory Authority: RCW 41.05.010 and 34.05.250. WSR 91-14-025, § 182-16-020, filed 6/25/91, effective 7/26/91.]



(Effective until January 1, 2020)

182-16-055
Mailing address changes.

(1) During the appeal process if the appellant's mailing address changes, the appellant must notify the public employees benefits board (PEBB) appeals unit as soon as possible.
(2) If the appellant does not notify the PEBB appeals unit of a change in the appellant's mailing address and the PEBB appeals unit continues to serve notices and other important documents to the appellant's last known mailing address, the documents will be deemed served on the appellant.
(3) This requirement to provide notice of an address change is in addition to WAC 182-08-198, 182-08-199, 182-12-128, and 182-12-262 that require a subscriber to update their address.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-055, filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-055, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-055, filed 9/25/14, effective 1/1/15.]
(Effective January 1, 2020)

182-16-055

Mailing address changes.

(1) During the appeal process if the appellant's mailing address changes, the appellant must notify the public employees benefits board (PEBB) appeals unit as soon as possible.
(2) If the appellant does not notify the PEBB appeals unit of a change in the appellant's mailing address and the PEBB appeals unit continues to serve notices and other important documents to the appellant's last known mailing address, the documents will be deemed served on the appellant.
(3) This requirement to provide notice of an address change is in addition to WAC 182-08-191 that require a subscriber to update their address.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-055, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-055, filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.021, 41.05.160, 2016 c 67, and PEBB policy resolutions. WSR 16-20-080, § 182-16-055, filed 10/4/16, effective 1/1/17. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-055, filed 9/25/14, effective 1/1/15.]



182-16-058
Service or serve.

(1) When the rules in this chapter or in other public employees benefits board (PEBB) program rules or statutes require a party to serve copies of documents on other parties, a party must send copies of the documents to all other parties or their representatives as described in this chapter. In this section, requirements for service or delivery by a party apply also when service is required by the presiding officer, review officer or officers, or hearing officer.
(2) Unless otherwise stated in applicable law, documents may be sent only as identified in this chapter to accomplish service. A party may serve someone by:
(a) Personal service (hand delivery);
(b) First class, registered, or certified mail sent via the United States Postal Service or Washington state consolidated mail services;
(c) Fax;
(d) Commercial delivery service; or
(e) Legal messenger service.
(3) A party must serve all other parties or their representatives whenever the party files a motion, pleading, brief, or other document with the presiding officer, review officer or officers, or hearing officer's office, or when required by law.
(4) Service is complete when:
(a) Personal service is made;
(b) Mail is properly stamped, addressed, and deposited in the United States Postal Service;
(c) Mail is properly addressed, and deposited in the Washington state consolidated mail services;
(d) Fax produces proof of transmission;
(e) A parcel is delivered to a commercial delivery service with charges prepaid; or
(f) A parcel is delivered to a legal messenger service with charges prepaid.
(5) A party may prove service by providing any of the following:
(a) A signed affidavit or certificate of mailing;
(b) The certified mail receipt signed by the person who received the parcel;
(c) A signed receipt from the person who accepted the commercial delivery service or legal messenger service parcel;
(d) Proof of fax transmission.
(6) Service cannot be made by electronic mail unless mutually agreed to in advance and in writing by the parties.
(7) If the document is a subpoena, follow the compliance procedure as described in WAC 182-16-3130.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-058, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-064
Applicable rules and laws.

A presiding officer, review officer or officers, or hearing officer must first apply the applicable public employees benefits board (PEBB) program rules adopted in the Washington Administrative Code (WAC). If no PEBB program rule applies, the presiding officer, review officer or officers, or hearing officer must decide the issue according to the best legal authority and reasoning available, including federal and Washington state constitutions, statutes, regulations, significant decisions indexed as described in WAC 182-16-130, and court decisions.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-064, filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-064, filed 9/25/14, effective 1/1/15.]
(Effective January 1, 2020)

182-16-064

Applicable rules and laws.

(1) An employing agency must apply public employees benefits board (PEBB) program rules adopted in the Washington Administrative Code (WAC) and follow instructions from the authority.
(2) A presiding officer, review officer or officers, or hearing officer must first apply the applicable PEBB program rules adopted in the WAC. If no PEBB program rule applies, the presiding officer, review officer or officers, or hearing officer must decide the issue according to the best legal authority and reasoning available, including federal and Washington state constitutions, statutes, regulations, significant decisions indexed as described in WAC 182-16-130, and court decisions.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-064, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-064, filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-064, filed 9/25/14, effective 1/1/15.]



(Effective until January 1, 2020)

182-16-066
Burden of proof, standard of proof, and presumptions.

(1) The burden of proof is a party's responsibility to provide evidence regarding disputed facts and persuade the presiding officer, review officer or officers, or hearing officer that a position is correct based on the standard of proof.
(2) Standard of proof refers to the amount of evidence needed to prove a party's position. Unless stated otherwise in rules or law, the standard of proof brief adjudicative proceeding or formal administrative in a hearing is a preponderance of the evidence, meaning that something is more likely to be true than not.
(3) Public officers and agencies are presumed to have properly performed their duties and acted as described in the law, unless substantial evidence to the contrary is presented. A party challenging this presumption bears the burden of proof.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033, § 182-16-066 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-066, filed 9/25/14, effective 1/1/15.]
(Effective January 1, 2020)

182-16-066

Burden of proof, standard of proof, and presumptions.

(1) The burden of proof is a party's responsibility to provide evidence regarding disputed facts and persuade the presiding officer, review officer or officers, or hearing officer that a position is correct based on the standard of proof. Unless stated otherwise in rules or law, the appellant has the burden of proof in a brief adjudicative proceeding or formal administrative hearing.
(2) Standard of proof refers to the amount of evidence needed to prove a party's position. Unless stated otherwise in rules or law, the standard of proof in a brief adjudicative proceeding or formal administrative hearing is a preponderance of the evidence, meaning that something is more likely to be true than not.
(3) Public officers and agencies are presumed to have properly performed their duties and acted as described in the law, unless substantial evidence to the contrary is presented. A party challenging this presumption bears the burden of proof.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-066, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033, § 182-16-066 (Admin #2018-03), filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-066, filed 9/25/14, effective 1/1/15.]



(Effective until January 1, 2020)

182-16-120
Computation of time.

(1) In computing any period of time prescribed by this chapter, the day of the event from which the time begins to run is not included. For example, if an initial order is served on Tuesday and the party has twenty-one days to request a review, start counting the days with Wednesday.
(2) Except as provided in subsection (3) of this section, the last day of the period so computed is included unless it is a Saturday, Sunday, or legal holiday as defined in RCW 1.16.050, in which case the period extends to the end of the next business day.
(3) When the period of time prescribed or allowed is less than ten days, intermediate Saturdays, Sundays and legal holidays shall be excluded in the computation.
(4) The deadline is 5:00 p.m. on the last day of the computed period.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-120, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-120

Computation of time.

(1) In computing any period of time prescribed by this chapter, the day of the event from which the time begins to run is not included. (For example, if an initial order is served on Friday and the party has twenty-one days to request a review, start counting the days with Saturday.)
(2) As provided in subsection (3) of this section, the last day of the period so computed is included unless it is a Saturday, Sunday, or legal holiday as defined in RCW 1.16.050, in which case the period extends to the end of the next business day.
(3) When the period of time prescribed or allowed is ten days or less, intermediate Saturdays, Sundays and legal holidays shall be excluded in the computation.
(4) The deadline is 5:00 p.m. on the last day of the computed period.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-120, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-120, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-130
Index of significant decisions.

(1) A final decision may be relied upon, used, or cited as precedent by a party if the final order has been indexed in the authority's index of significant decisions in accordance with RCW 34.05.473 (1)(b).
(2) An index of significant decisions is available to the public on the health care authority's (HCA) web site. As decisions are indexed they will be available on the web site.
(3) A final decision published in the index of significant decisions may be removed from the index when:
(a) A published decision entered by the court of appeals or the supreme court reverses an indexed final decision; or
(b) HCA determines that the indexed final decision is no longer precedential due to changes in statute, rule, or policy.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-130, filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-130, filed 9/25/14, effective 1/1/15.]
(Effective January 1, 2020)

182-16-130

Index of significant decisions.

(1) A final decision may be relied upon, used, or cited as precedent by a party only if the final order has been indexed in the authority's index of significant decisions in accordance with RCW 34.05.473 (1)(b).
(2) An index of significant decisions is available to the public on the health care authority's (HCA) web site. As decisions are indexed they will be available on the web site.
(3) A final decision published in the index of significant decisions may be removed from the index when:
(a) A published decision entered by the court of appeals or the supreme court reverses an indexed final decision; or
(b) HCA determines that the indexed final decision is no longer precedential due to changes in statute, rule, or policy.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-130, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-130, filed 10/29/18, effective 1/1/19. Statutory Authority: RCW 41.05.160 and 2013 2nd sp.s. c 4. WSR 14-20-058 (PEBB Admin 2014-02), § 182-16-130, filed 9/25/14, effective 1/1/15.]



(Effective until January 1, 2020)

182-16-2000
Brief adjudicative proceedings.

Pursuant to RCW 34.05.482, the authority will use brief adjudicative proceedings for issues identified in this chapter when doing so would not violate law, or when protection of the public interest does not require the authority to give notice and an opportunity to participate to persons other than the parties, or the issue and interests involved in the controversy do not warrant use of the procedures of RCW 34.05.413 through 34.05.479 which govern formal administrative hearings.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2000, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-2000

Brief adjudicative proceedings.

Pursuant to RCW 34.05.482, the authority will use brief adjudicative proceedings for issues identified in this chapter when doing so would not violate law, or when protection of the public interest does not require the authority to give notice and an opportunity to participate to persons other than the parties, or the issue and interests involved in the controversy do not warrant use of the procedures of RCW 34.05.413 through 34.05.476 which govern formal administrative hearings.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2000, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2000, filed 10/29/18, effective 1/1/19.]



182-16-2005
RecordBrief adjudicative proceeding.

The record in a brief adjudicative proceeding consists of any documents regarding the matter, considered or prepared by the presiding officer for the brief adjudicative proceeding or by the review officer or officers for any review. The authority's record does not have to constitute the exclusive basis for agency action, unless otherwise required by law.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2005, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-2010
Where to appeal a decision regarding eligibility, enrollment, premium payments, premium surcharges, a public employees benefits board (PEBB) wellness incentive, or the administration of benefits?

(1) Any current or former employee of a state agency or their dependent aggrieved by a decision made by the state agency with regard to public employees benefits board (PEBB) eligibility, enrollment, or premium surcharges may appeal that decision to the state agency by the process outlined in WAC 182-16-2020.
Note:
Eligibility decisions address whether a subscriber or a subscriber's dependent is entitled to PEBB 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.
(2) Any current or former employee of an employer group or their dependent who is aggrieved by a decision made by an employer group with regard to PEBB eligibility, enrollment, or premium surcharges may appeal that decision to the employer group through the process established by the employer group.
Exception:
Any current or former employee of an employer group aggrieved by a decision regarding life insurance, long-term disability (LTD) insurance, eligibility to participate in the PEBB wellness incentive program, or eligibility to receive a PEBB wellness incentive may appeal that decision to the PEBB appeals committee by the process described in WAC 182-16-2030.
(3) Any subscriber or dependent aggrieved by a decision made by the PEBB program with regard to PEBB eligibility, enrollment, premium payments, premium surcharges, eligibility to participate in the PEBB wellness incentive program, or eligibility to receive a PEBB wellness incentive, may appeal that decision to the PEBB appeals unit by the process described in WAC 182-16-2030.
(4) Any PEBB enrollee aggrieved by a decision regarding the administration of a health plan, life insurance, or long-term disability insurance may appeal that decision by following the appeal provisions of those plans, with the exception of:
(a) Enrollment decisions;
(b) Premium payment decisions other than life insurance premium payment decisions; and
(c) Eligibility decisions.
(5) Any PEBB enrollee aggrieved by a decision regarding the administration of PEBB long-term care insurance or property and casualty insurance may appeal that decision by following the appeal provisions of those plans.
(6) Any PEBB employee aggrieved by a decision regarding the administration of a benefit offered under the state's salary reduction plan may appeal that decision by the process described in WAC 182-16-2050.
(7) Any subscriber aggrieved by a decision made by the PEBB wellness incentive program contracted vendor regarding the completion of the PEBB wellness incentive program requirements, or a request for a reasonable alternative to a wellness incentive program requirement, may appeal that decision by the process described in WAC 182-16-2040.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2010, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-2010

Appealing a decision regarding public employees benefits board (PEBB) eligibility, enrollment, premium payments, premium surcharges, a wellness incentive, or the administration of benefits.

(1) Any current or former employee of a state agency or their dependent aggrieved by a decision made by the state agency with regard to public employees benefits board (PEBB) eligibility, enrollment, or premium surcharges may appeal that decision to the state agency by the process described in WAC 182-16-2020.
Note:
Eligibility decisions address whether a subscriber or a subscriber's dependent is entitled to PEBB benefits, 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.
(2) Any current or former employee of an employer group or their dependent who is aggrieved by a decision made by an employer group with regard to PEBB eligibility, enrollment, or premium surcharges may appeal that decision to the employer group through the process established by the employer group.
Exception:
Any current or former employee of an employer group aggrieved by a decision regarding life insurance, long-term disability (LTD) insurance, eligibility to participate in the PEBB wellness incentive program, or eligibility to receive a PEBB wellness incentive may appeal that decision to the PEBB appeals unit by the process described in WAC 182-16-2030.
(3) Any subscriber or dependent aggrieved by a decision made by the PEBB program with regard to PEBB eligibility, enrollment, premium payments, premium surcharges, eligibility to participate in the PEBB wellness incentive program, or eligibility to receive a PEBB wellness incentive, may appeal that decision to the PEBB appeals unit by the process described in WAC 182-16-2030.
(4) Any enrollee aggrieved by a decision regarding the administration of a health plan, life insurance, accidental death and dismemberment (AD&D) insurance, or long-term disability insurance may appeal that decision by following the appeal provisions of those plans, with the exception of:
(a) Enrollment decisions;
(b) Premium payment decisions other than life insurance or AD&D insurance premium payment decisions; and
(c) Eligibility decisions.
(5) Any PEBB enrollee aggrieved by a decision regarding the administration of PEBB long-term care insurance or property and casualty insurance may appeal that decision by following the appeal provisions of those plans.
(6) Any PEBB employee aggrieved by a decision regarding the administration of a benefit offered under the state's salary reduction plan may appeal that decision by the process described in WAC 182-16-2050.
(7) Any subscriber aggrieved by a decision made by the PEBB wellness incentive program contracted vendor regarding the completion of the PEBB wellness incentive program requirements, or a request for a reasonable alternative to a wellness incentive program requirement, may appeal that decision by the process described in WAC 182-16-2040.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2010, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2010, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-2020
How can a current or former employee or an employee's dependent appeal a decision made by a state agency about eligibility, premium surcharge, or enrollment in benefits?

(1) An eligibility, premium surcharge, or enrollment decision made by a state agency may be appealed by submitting a written request for administrative review to the state agency. The state agency must receive the request for administrative review no later than thirty days after the date of the denial notice. The contents of the request for administrative review are to be provided as described in WAC 182-16-2070.
(a) Upon receiving the request for administrative review, the state agency shall perform a complete review of the denial by one or more staff who did not take part in the decision resulting in the denial. As part of the administrative review, the state agency may hold a formal meeting or formal administrative hearing, but is not required to do so.
(b) The state agency shall render a written decision within thirty days of receiving the request for administrative review. The written decision shall be sent to the employee or employee's dependent who submitted the request for administrative review and must include a description of appeal rights. The state agency shall also send a copy of the state agency's written decision to the state agency's administrator (or designee) and to the public employees benefits board (PEBB) appeals unit. If a state agency fails to render a written decision within thirty days of receiving the written request for administrative review, the request for administrative review may be considered denied and the original underlying state agency decision may be appealed to the PEBB appeals unit by following the process in this section.
(c) The state agency may reverse eligibility, premium surcharge, or enrollment decisions based only on circumstances that arose due to delays caused by the state agency or errors made by the state agency.
(2) Any current or former employee or employee's dependent who disagrees with the state agency's decision in response to a written request for administrative review, as described in subsection (1) of this section, may request a brief adjudicative proceeding to be conducted by the authority by submitting a written request to the PEBB appeals unit.
(a) The PEBB appeals unit must receive the request for a brief adjudicative proceeding no later than thirty days after the date of the state agency's written decision on the request for administrative review. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.
(i) The PEBB appeals unit shall notify the appellant in writing when the request for a brief adjudicative proceeding has been received.
(ii) Once the PEBB appeals unit receives a request for a brief adjudicative proceeding, the PEBB appeals unit will send a request for documentation and information to the applicable state agency. The state agency will then have two business days to respond to the request and provide the requested documentation and information. The state agency will also send a copy of the documentation and information to the employee, former employee, or the employee's dependent.
(iii) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.
(b) If an employee fails to timely request a brief adjudicative proceeding to appeal the state agency's written decision within thirty days by following the process in (a) of this subsection, the state agency's prior written decision becomes the health care authority's final decision.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2020, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-2020

Appealing a decision made by a state agency about eligibility, premium surcharges, or enrollment in benefits.

(1) An eligibility, premium surcharges, or enrollment decision made by a state agency may be appealed by submitting a written request for administrative review to the state agency. The state agency must receive the request for administrative review no later than thirty days after the date of the denial notice. The contents of the request for administrative review are to be provided as described in WAC 182-16-2070.
(a) Upon receiving the request for administrative review, the state agency must perform a complete review of the denial by one or more staff who did not take part in the decision resulting in the denial.
(b) The state agency must render a written decision within thirty days of receiving the request for administrative review. The written decision must be sent to the employee or employee's dependent who submitted the request for administrative review and must include a description of appeal rights. The state agency must also send a copy of the state agency's written decision to the state agency's administrator (or designee) and to the public employees benefits board (PEBB) appeals unit. If a state agency fails to render a written decision within thirty days of receiving the written request for administrative review, the request for administrative review may be considered denied as of the thirty-first day and the original underlying state agency decision may be appealed to the PEBB appeals unit by following the process in this section.
(c) The state agency may reverse eligibility, premium surcharges, or enrollment decisions as permitted by WAC 182-08-187.
(2) Any current or former employee or employee's dependent who disagrees with the state agency's decision in response to a written request for administrative review, as described in subsection (1) of this section, may request a brief adjudicative proceeding to be conducted by the authority by submitting a written request to the PEBB appeals unit.
(a) The PEBB appeals unit must receive the request for a brief adjudicative proceeding no later than thirty days after the date of the state agency's written decision on the request for administrative review. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.
(i) The PEBB appeals unit must notify the appellant in writing when the request for a brief adjudicative proceeding has been received.
(ii) Once the PEBB appeals unit receives a request for a brief adjudicative proceeding, the PEBB appeals unit will send a request for documentation and information to the applicable state agency. The state agency will then have two business days to respond to the request and provide the requested documentation and information. The state agency will also send a copy of the documentation and information to the appellant.
(iii) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.
(b) If an employee fails to timely request a brief adjudicative proceeding to appeal the state agency's written decision within thirty days by following the process in (a) of this subsection, the state agency's prior written decision becomes the health care authority's final decision without further action.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2020, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2020, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-2030
Appealing a public employees benefits board (PEBB) program decision regarding eligibility, enrollment, premium payments, premium surcharges, a PEBB wellness incentive, or certain decisions made by an employer group?

(1) A decision made by the public employees benefits board (PEBB) program regarding eligibility, enrollment, premium payments, premium surcharges, a PEBB wellness incentive, may be appealed by submitting a request to the PEBB appeals unit for a brief adjudicative proceeding to be conducted by the authority.
(2) A decision made by an employer group regarding life insurance, LTD insurance, eligibility to participate in the PEBB wellness incentive program, or eligibility to receive a PEBB wellness incentive may be appealed by submitting a request to the PEBB appeals unit for a brief adjudicative proceeding to be conducted by the authority.
(3) The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.
(4) The request for a brief adjudicative proceeding from a current or former employee or employee's dependent must be received by the PEBB appeals unit no later than thirty days after the date of the denial notice.
(5) The request for a brief adjudicative proceeding from a retiree, self-pay enrollee, or dependent of a retiree or self-pay enrollee must be received by the PEBB appeals unit no later than sixty days after the date of the denial notice.
(6) The PEBB appeals unit shall notify the appellant in writing when the request for a brief adjudicative proceeding has been received.
(7) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.
(8) Failing to timely request a brief adjudicative proceeding to appeal a decision made under this section within the applicable time frame described in subsections (4) and (5) of this section, will result in the prior PEBB program decision becoming the authority's final decision without further employing agency action.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2030, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-2030

Appealing a public employees benefits board (PEBB) program decision regarding eligibility, enrollment, premium payments, premium surcharges, a PEBB wellness incentive, or certain decisions made by an employer group.

(1) A decision made by the public employees benefits board (PEBB) program regarding eligibility, enrollment, premium payments, premium surcharges, a PEBB wellness incentive, may be appealed by submitting a request to the PEBB appeals unit for a brief adjudicative proceeding to be conducted by the authority.
(2) A decision made by an employer group regarding life insurance, LTD insurance, eligibility to participate in the PEBB wellness incentive program, or eligibility to receive a PEBB wellness incentive may be appealed by submitting a request to the PEBB appeals unit for a brief adjudicative proceeding to be conducted by the authority.
(3) The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.
(4) The request for a brief adjudicative proceeding from a current or former employee or employee's dependent must be received by the PEBB appeals unit no later than thirty days after the date of the denial notice.
(5) The request for a brief adjudicative proceeding from a retiree, self-pay enrollee, or dependent of a retiree or self-pay enrollee must be received by the PEBB appeals unit no later than sixty days after the date of the denial notice.
(6) The PEBB appeals unit must notify the appellant in writing when the request for a brief adjudicative proceeding has been received.
(7) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.
(8) Failing to timely request a brief adjudicative proceeding to appeal a decision made under this section within the applicable time frame described in subsections (4) and (5) of this section, will result in the prior PEBB program decision becoming the authority's final decision without further action.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2030, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2030, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-2040
How can a subscriber appeal a decision regarding the administration of wellness incentive program requirements?

(1) Any subscriber aggrieved by a decision regarding the completion of the wellness incentive program requirements, or request for a reasonable alternative to a wellness incentive program requirement, may appeal that decision to the public employees benefits board (PEBB) wellness incentive program contracted vendor.
(2) Any subscriber who disagrees with a decision in response to an appeal filed with the PEBB wellness incentive program contracted vendor may appeal the decision by submitting a request for a brief adjudicative proceeding to the PEBB appeals unit.
(a) The request for a brief adjudicative proceeding from a current or former employee must be received by the PEBB appeals unit no later than thirty days after the date of the denial notice. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.
(b) The request for a brief adjudicative proceeding from a retiree or self-pay subscriber must be received by the PEBB appeals unit no later than sixty days after the date of the denial notice. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.
(3) The PEBB appeals unit shall notify the appellant in writing when the request for a brief adjudicative proceeding has been received.
(4) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.
(5) If a subscriber fails to timely request a brief adjudicative proceeding of a decision made under subsection (1) of this section within thirty days by following the process in WAC 182-16-2020(2), the decision of the PEBB wellness incentive program contracted vendor becomes the authority's final decision.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2040, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-2040

How can a subscriber appeal a decision regarding the administration of wellness incentive program requirements?

(1) Any subscriber aggrieved by a decision regarding the completion of the wellness incentive program requirements, or request for a reasonable alternative to a wellness incentive program requirement, may appeal that decision to the public employees benefits board (PEBB) wellness incentive program contracted vendor.
(2) Any subscriber who disagrees with a decision in response to an appeal filed with the PEBB wellness incentive program contracted vendor may appeal the decision by submitting a request for a brief adjudicative proceeding to the PEBB appeals unit.
(a) The request for a brief adjudicative proceeding from a current or former employee must be received by the PEBB appeals unit no later than thirty days after the date of the denial notice. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.
(b) The request for a brief adjudicative proceeding from a retiree or self-pay subscriber must be received by the PEBB appeals unit no later than sixty days after the date of the denial notice. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.
(3) The PEBB appeals unit must notify the appellant in writing when the request for a brief adjudicative proceeding has been received.
(4) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.
(5) If a subscriber fails to timely request a brief adjudicative proceeding of a decision made under subsection (1) of this section within thirty days by following the process in WAC 182-16-2020(2), the decision of the PEBB wellness incentive program contracted vendor becomes the authority's final decision.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2040, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2040, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-2050
How can an employee who is eligible to participate in the state's salary reduction plan appeal a decision regarding the administration of benefits offered under the state's salary reduction plan?

(1) Any employee who disagrees with a decision that denies eligibility for, or enrollment in, a benefit offered under the state's salary reduction plan may appeal that decision by submitting a written request for administrative review to their state agency. The state agency must receive the written request for administrative review no later than thirty days after the date of the denial. The contents of the written request for administrative review are to be provided as described in WAC 182-16-2070.
(a) Upon receiving the written request for administrative review, the state agency shall perform a complete review of the denial by one or more staff who did not take part in the decision resulting in the denial.
(b) The state agency shall render a written decision within thirty days of receiving the request for administrative review. The written decision shall be sent to the employee who submitted the written request for review and must include a description of appeal rights. The state agency shall also send a copy of the state agency's administrator (or designee) and to the PEBB appeals unit. If a state agency fails to render a written decision within thirty days of receiving the written request for administrative review, the request for administrative review may be considered denied and the original underlying state agency decision may be appealed to the PEBB appeals unit by following the process in this section.
(2) Any employee who disagrees with the state agency's decision in response to a written request for administrative review, as described in this section, may request a brief adjudicative proceeding to be conducted by the authority by submitting a written request to the PEBB appeals unit.
(a) The PEBB appeals unit must receive the request for a brief adjudicative proceeding no later than thirty days after the date of the state agency's written decision on the request for administrative review. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.
(i) The PEBB appeals unit shall notify the appellant in writing when the request for a brief adjudicative proceeding has been received.
(ii) Once the PEBB appeals unit receives a request for a brief adjudicative proceeding, the PEBB appeals unit will send a request for documentation and information to the applicable state agency. The state agency will then have two business days to respond to the request. The state agency will also send a copy of the documentation and information to the employee.
(iii) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.
(b) If an employee fails to timely request a brief adjudicative proceeding to appeal a decision made under this section within thirty days by following the process described in this subsection, the state agency's prior written decision becomes the authority's final decision without further state agency action.
(3) Any employee aggrieved by a decision regarding a claim for benefits under the medical flexible spending arrangement (FSA) or dependent care assistance program (DCAP) offered under the state's salary reduction plan may appeal that decision to the authority's contracted vendor by following the appeal process of that contracted vendor.
(a) Any employee who disagrees with a decision in response to an appeal filed with the contracted vendor that administers the medical FSA and DCAP under the state's salary reduction plan may request a brief adjudicative proceeding by submitting a written request to the PEBB appeals unit. The PEBB appeals unit must receive the request for a brief adjudicative proceeding no later than thirty days after the date of the contracted vendor's appeal decision. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.
(i) The PEBB appeals unit shall notify the appellant in writing when the request for a brief adjudicative proceeding has been received.
(ii) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.
(b) If an employee fails to timely request a brief adjudicative proceeding to appeal a decision made under this section within thirty days by following the process described in this subsection, the contracted vendor's prior written decision becomes the authority's final decision.
(4) Any employee aggrieved by a decision regarding the administration of the premium payment plan offered under the state's salary reduction plan may request a brief adjudicative proceeding to be conducted by the authority by submitting a written request to the PEBB appeals unit for a brief adjudicative proceeding.
(a) The PEBB appeals unit must receive the request for a brief adjudicative proceeding no later than thirty days after the date of the denial notice by the PEBB program. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.
(i) The PEBB appeals unit shall notify the appellant in writing when the notice of appeal has been received.
(ii) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.
(b) If an employee fails to timely request a brief adjudicative proceeding to appeal a decision made under this section within thirty days by following the process described in this subsection, the PEBB program's prior written decision becomes the authority's final decision.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2050, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-2050

How can an employee appeal a decision regarding the administration of benefits offered under the salary reduction plan?

(1) Any employee who disagrees with a decision that denies eligibility for, or enrollment in, a benefit offered under the salary reduction plan may appeal that decision by submitting a written request for administrative review to their state agency. The state agency must receive the written request for administrative review no later than thirty days after the date of the denial. The contents of the written request for administrative review are to be provided as described in WAC 182-16-2070.
(a) Upon receiving the written request for administrative review, the state agency must perform a complete review of the denial by one or more staff who did not take part in the decision resulting in the denial.
(b) The state agency must render a written decision within thirty days of receiving the request for administrative review. The written decision must be sent to the employee who submitted the written request for review and must include a description of appeal rights. The state agency must also send a copy of the state agency's written decision to the state agency's administrator (or designee) and to the PEBB appeals unit. If a state agency fails to render a written decision within thirty days of receiving the written request for administrative review, the request for administrative review may be considered denied as of the thirty-first day and the original underlying state agency decision may be appealed to the PEBB appeals unit by following the process in this section.
(2) Any employee who disagrees with the state agency's decision in response to a written request for administrative review, as described in this section, may request a brief adjudicative proceeding to be conducted by the authority by submitting a written request to the PEBB appeals unit.
(a) The PEBB appeals unit must receive the request for a brief adjudicative proceeding no later than thirty days after the date of the state agency's written decision on the request for administrative review. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.
(i) The PEBB appeals unit must notify the appellant in writing when the request for a brief adjudicative proceeding has been received.
(ii) Once the PEBB appeals unit receives a request for a brief adjudicative proceeding, the PEBB appeals unit will send a request for documentation and information to the applicable state agency. The state agency will then have two business days to respond to the request and provide the documentation and information requested. The state agency will also send a copy of the documentation and information to the employee.
(iii) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.
(b) If an employee fails to timely request a brief adjudicative proceeding to appeal a decision made under this section within thirty days by following the process described in this subsection, the state agency's prior written decision becomes the authority's final decision without further action.
(3) Any employee aggrieved by a decision regarding a claim for benefits under the medical flexible spending arrangement (FSA) or dependent care assistance program (DCAP) offered under the salary reduction plan may appeal that decision to the authority's contracted vendor by following the appeal process of that contracted vendor.
(a) Any employee who disagrees with a decision in response to an appeal filed with the contracted vendor that administers the medical FSA and DCAP under the salary reduction plan may request a brief adjudicative proceeding by submitting a written request to the PEBB appeals unit. The PEBB appeals unit must receive the request for a brief adjudicative proceeding no later than thirty days after the date of the contracted vendor's appeal decision. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.
(i) The PEBB appeals unit must notify the appellant in writing when the request for a brief adjudicative proceeding has been received.
(ii) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.
(b) If an employee fails to timely request a brief adjudicative proceeding to appeal a decision made under this section within thirty days by following the process described in this subsection, the contracted vendor's prior written decision becomes the authority's final decision.
(4) Any employee aggrieved by a decision regarding the administration of the premium payment plan offered under the salary reduction plan may request a brief adjudicative proceeding to be conducted by the authority by submitting a written request to the PEBB appeals unit for a brief adjudicative proceeding.
(a) The PEBB appeals unit must receive the request for a brief adjudicative proceeding no later than thirty days after the date of the denial notice by the PEBB program. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.
(i) The PEBB appeals unit must notify the appellant in writing when the notice of appeal has been received.
(ii) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.
(b) If an employee fails to timely request a brief adjudicative proceeding to appeal a decision made under this section within thirty days by following the process described in this subsection, the PEBB program's prior written decision becomes the authority's final decision.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2050, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2050, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-2060
How can an entity or organization appeal a decision of the health care authority to deny an employer group application?

(1) An entity or organization whose employer group application is denied by the authority may appeal the decision by submitting a request for a brief adjudicative proceeding to the public employees benefits board (PEBB) appeals unit. For rules regarding eligible entities, see WAC 182-12-111.
(2) The PEBB appeals unit must receive the request for a brief adjudicative proceeding no later than thirty days after the date of the denial notice. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.
(3) The PEBB appeals unit shall notify the appellant in writing when the request for a brief adjudicative proceeding has been received.
(4) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.
(5) Failing to timely request a brief adjudicative proceeding to appeal a decision made under this section within thirty days by following the process described in subsection (2) of this section, will result in the prior PEBB program decision becoming the authority's final decision.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2060, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-2060

How can an entity or organization appeal a decision of the health care authority to deny an employer group application?

(1) An entity or organization whose employer group application is denied by the authority may appeal the decision by submitting a request for a brief adjudicative proceeding to the public employees benefits board (PEBB) appeals unit. For rules regarding eligible entities, see WAC 182-12-111.
(2) The PEBB appeals unit must receive the request for a brief adjudicative proceeding no later than thirty days after the date of the denial notice. The contents of the request for a brief adjudicative proceeding are to be provided as described in WAC 182-16-2070.
(3) The PEBB appeals unit must notify the appellant in writing when the request for a brief adjudicative proceeding has been received.
(4) The brief adjudicative proceeding will be conducted by a presiding officer designated by the director.
(5) Failing to timely request a brief adjudicative proceeding to appeal a decision made under this section within thirty days by following the process described in subsection (2) of this section, will result in the prior PEBB program decision becoming the authority's final decision.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2060, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2060, filed 10/29/18, effective 1/1/19.]



182-16-2070
What should a written request for administrative review and a request for brief adjudicative proceeding contain?

A written request for administrative review and a request for brief adjudicative proceeding should contain:
(1) The name and mailing address of the party requesting an administrative review or the brief adjudicative proceeding;
(2) The name and mailing address of the appealing party's representative, if any;
(3) Documentation, or reference to documentation, of decisions previously rendered through the appeal process, if any;
(4) A statement identifying the specific portion of the decision being appealed and clarifying what is believed to be unlawful or in error;
(5) A statement of facts in support of the appealing party's position;
(6) Any information or documentation that the appealing party would like considered;
(7) The type of relief sought; and
(8) The signature of the appealing party or the appealing party's representative.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2070, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-2080
Who can appeal or represent a party in a brief adjudicative proceeding?

(1) The appellant may act as their own representative or may choose to be represented by another person, except employees of the health care authority (HCA) or HCA's authorized agents.
(2) If the appellant is represented by a person who is not an attorney admitted to practice in Washington state, the representative must provide the presiding officer and other parties with the representative's name, address, and telephone number. In cases involving confidential information, the nonattorney representative must provide the PEBB appeals unit and other parties with a signed, written consent permitting release to the nonattorney representative of the appellant's personal health information protected by state or federal law.
(3) An attorney admitted to practice law in Washington state representing the appellant must file a written notice of appearance containing the attorney's name, address, and telephone number with the presiding officer's office and serve all parties with the notice. In cases involving confidential information, the attorney must provide the PEBB appeals unit and other parties with a signed, written consent permitting release to the attorney of the appellant's personal health information protected by state or federal law. If the appellant's attorney representative no longer represents the appellant, then the attorney must file a written notice of withdrawal of representation with the presiding officer or review officer or officers' office and serve all parties with the notice.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2080, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-2080

Who can appeal or represent a party in a brief adjudicative proceeding?

(1) The appellant may act as their own representative or may choose to be represented by another person, except that employees of the health care authority (HCA) or HCA's authorized agents may not represent an appellant, unless approved by a presiding officer or review officer.
(2) If the appellant is represented by a person who is not an attorney admitted to practice in Washington state, the representative must provide the presiding officer and other parties with the representative's name, address, and telephone number. In cases involving confidential information, the nonattorney representative must provide the PEBB appeals unit and other parties with a signed, written consent permitting release to the nonattorney representative of the appellant's health information protected by state or federal law.
(3) An attorney admitted to practice law in Washington state representing the appellant must file a written notice of appearance containing the attorney's name, address, and telephone number with the presiding officer's office and serve all parties with the notice. In cases involving confidential information, the attorney must provide the PEBB appeals unit and other parties with a signed, written consent permitting release to the attorney of the appellant's health information protected by state or federal law. If the appellant's attorney representative no longer represents the appellant, then the attorney must file a written notice of withdrawal of representation with the presiding officer or review officer or officers' office and serve all parties with the notice.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2080, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2080, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-2085
Continuances.

The presiding officer or review officer or officers may grant, in their sole discretion, a request for a continuance on motion of the appellant, the authority, or on its own motion. The continuance may be up to thirty calendar days.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2085, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-2085

Continuances.

The presiding officer or review officer or officers may grant, in their sole discretion, a request for a continuance on motion of the appellant, the authority, or on their own motion. The continuance may be up to thirty calendar days.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2085, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2085, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-2090
Initial order.

Unless a continuance has been granted, within ten days after the PEBB appeals unit receives a request for a brief adjudicative proceeding, the presiding officer shall render a written initial order that addresses the issue or issues raised by the appellant in their appeal. The presiding officer shall serve a copy of the initial order on all parties and the initial order shall contain information on how the appellant may request review of the initial order.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2090, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-2090

Initial order.

Unless a continuance has been granted, within ten days after the PEBB appeals unit receives a request for a brief adjudicative proceeding, the presiding officer shall render a written initial order that addresses the issue or issues raised by the appellant in their appeal. The presiding officer must serve a copy of the initial order on all parties and the initial order must contain information on how the appellant may request review of the initial order.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2090, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2090, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-2100
How to request a review of an initial order resulting from a brief adjudicative proceeding.

(1) An appellant who has received an initial order upholding an employing agency decision, PEBB program decision, or a decision made by PEBB program contracted vendor, may request review of the initial order by the authority. The appellant must file a written request for review of the initial order or by making an oral request for review of the initial order with the public employees benefits board (PEBB) appeals unit within twenty-one days after service of the initial order. The written request for review of the initial order must be provided using the contact information included in the initial order. If the appellant fails to request review of the initial order within twenty-one days, the order becomes the final order without any further action by the authority.
(2) Upon timely request by the appellant, a review of an initial order will be performed by one or more review officers designated by the director of the authority.
(3) If the parties have not requested review, the authority may review an order resulting from a brief adjudicative proceeding on its own motion, and without notice to the parties, but it may not take action on review less favorable to any party than the initial order without giving that party notice and an opportunity to explain that party's view of the matter.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2100, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-2100

How to request a review of an initial order resulting from a brief adjudicative proceeding.

(1) An appellant who has received an initial order upholding an employing agency decision, public employees benefits board (PEBB) program decision, or a decision made by PEBB program contracted vendor, may request review of the initial order by the authority. The appellant must file a written request for review of the initial order or make an oral request for review of the initial order with the PEBB appeals unit within twenty-one days after service of the initial order. The written or oral request for review of the initial order must be made by using the contact information included in the initial order. If the appellant fails to request review of the initial order within twenty-one days, the order becomes the final order without further action by the authority.
(2) Upon timely request by the appellant, a review of an initial order will be performed by one or more review officers designated by the director of the authority.
(3) If the appellant has not requested review, the authority may review an order resulting from a brief adjudicative proceeding on its own motion, and without notice to the parties, but it may not take action on review less favorable to any party than the initial order without giving that party notice and an opportunity to explain that party's view of the matter.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2100, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2100, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-2105
Withdrawing the request for a brief adjudicative proceeding or review of an initial order.

(1) The appellant may withdraw the request for a brief adjudicative proceeding or review of an initial order for any reason, and at any time, by contacting the public employees benefits board (PEBB) appeals unit. The PEBB appeals unit will present the withdrawal request to the presiding officer or review officer or officers.
(2) The request for withdrawal must be made in writing.
(3) After a withdrawal request is received, the presiding officer or review officer or officers must enter and serve a written order dismissing the appeal.
(4) If an appellant withdraws a request for a brief adjudicative proceeding or review of an initial order, the appellant may not reinstate the request for a brief adjudicative proceeding or review of an initial order unless time remains on their original appeal period.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2105, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-2105

Withdrawing the request for a brief adjudicative proceeding or review of an initial order.

(1) The appellant may withdraw the request for a brief adjudicative proceeding or review of an initial order for any reason, and at any time, by contacting the public employees benefits board (PEBB) appeals unit. The PEBB appeals unit will present the withdrawal request to the presiding officer or review officer or officers.
(2) The request for withdrawal must be made in writing.
(3) After a withdrawal request is received, the presiding officer or review officer or officers must enter and serve a written order dismissing the brief adjudicative proceeding or review of an initial order.
(4) If an appellant withdraws a request for a brief adjudicative proceeding or review of an initial order, the appellant may not reinstate the request for a brief adjudicative proceeding or review of an initial order unless time remains on their original appeal period.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2105, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2105, filed 10/29/18, effective 1/1/19.]



182-16-2110
Final order.

(1) A final order issued by the review officer or officers will be issued in writing and include a brief statement of the reasons for the decision.
(2) The final order must be rendered and served within twenty days of the date of the initial order or of the date the request for review of the initial order was received by the PEBB appeals unit, whichever is later.
(3) The final order will include a notice that reconsideration and judicial review may be available.
(4) A request for review of the initial order is deemed denied if the authority does not issue a final order within twenty days after the request for review of the initial order is filed.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2110, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-2120
Request for reconsideration.

(1) A request for reconsideration asks the review officer or officers to reconsider the final order because the party believes the review officer or officers made a mistake of law, mistake of fact, or clerical error.
(2) A request for reconsideration must state in writing why the party wants the final order to be reconsidered.
(3) Requests for reconsideration must be filed with the review officer or officers who entered the final order.
(4) If a party files a request for reconsideration:
(a) The review officer or officers must receive the request for reconsideration on or before the tenth business day after the service date of the final order.
(b) The party filing the request must send copies of the request to all other parties.
(c) Within five business days of receiving a request for reconsideration, the review officer or officers must serve all parties a notice that provides the date the request for reconsideration was received.
(5) The other parties may respond to the request for reconsideration. The response must state in writing why the final order should stand. Responses are optional. If a party chooses not to respond, that party will not be prejudiced because of that choice.
(a) Responses to a request for reconsideration must be received by the review officer or officers no later than seven business days after the service date of the review officer's or officers' notice as described in subsection (4)(c) of this section, or the response will not be considered.
(b) Service of responses to a request for reconsideration must be made to all parties.
(6) If a party needs more time to file a request for reconsideration or respond to a request for reconsideration, the review officer or officers may extend the required time frame if the party makes a written request providing a good reason for the request within the required time frame.
(7) Unless the request for reconsideration is denied as untimely filed under WAC 182-16-2120 (4)(a), the same review officer or officers who entered the final order, if reasonably available, will also consider the request as well as any responses received.
(8) The decision on the request for reconsideration must be in the form of a written order denying the request, granting the request in whole or in part and issuing a new written final order, or granting the petition and setting the matter for further hearing.
(9) If the review officer or officers do not send an order on the request for reconsideration within twenty calendar days of the date of the notice described in subsection (4)(c) of this section, the request is deemed denied.
(10) If any party files a request for reconsideration of the final order, the reconsideration process must be completed before any judicial review may be requested. However, the filing of a petition for reconsideration is not required before requesting judicial review.
(11) An order denying a request for reconsideration is not subject to judicial review.
(12) No evidence may be offered in support of a motion for reconsideration, except newly discovered evidence that is material for the party moving for reconsideration and that the party could not with reasonable diligence have discovered and produced at the hearing or before the ruling on a dispositive motion.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2120, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-2120

Request for reconsideration.

(1) A request for reconsideration asks the review officer or officers to reconsider the final order because the party believes the review officer or officers made a mistake of law, mistake of fact, or clerical error.
(2) A request for reconsideration must state in writing why the party wants the final order to be reconsidered.
(3) Requests for reconsideration must be filed with the review officer or officers who entered the final order.
(4) If a party files a request for reconsideration:
(a) The review officer or officers must receive the request for reconsideration on or before the tenth business day after the service date of the final order.
(b) The party filing the request must send copies of the request to all other parties.
(c) Within five business days of receiving a request for reconsideration, the review officer or officers must serve all parties a notice that provides the date the request for reconsideration was received.
(5) The other parties may respond to the request for reconsideration. The response must state in writing why the final order should stand. Responses are optional. If a party chooses not to respond, that party will not be prejudiced because of that choice.
(a) Responses to a request for reconsideration must be received by the review officer or officers no later than seven business days after the service date of the review officer's or officers' notice as described in subsection (4)(c) of this section, or the response will not be considered.
(b) Service of responses to a request for reconsideration must be made to all parties.
(6) If a party needs more time to file a request for reconsideration or respond to a request for reconsideration, the review officer or officers may extend the required time frame if the party makes a written request providing a good reason for the request within the required time frame.
(7) Unless the request for reconsideration is denied as untimely filed under WAC 182-16-2120 (4)(a), the same review officer or officers who entered the final order, if reasonably available, will also consider the request as well as any responses received.
(8) The decision on the request for reconsideration must be in the form of a written order denying the request, granting the request in whole or in part and issuing a new written final order, or granting the petition and setting the matter for further hearing.
(9) If the review officer or officers do not send an order on the request for reconsideration within twenty calendar days of the date of the notice described in subsection (4)(c) of this section, the request is deemed denied.
(10) If any party files a request for reconsideration of the final order, the reconsideration process must be completed before any judicial review may be requested. However, the filing of a petition for reconsideration is not required before requesting judicial review.
(11) An order denying a request for reconsideration is not subject to judicial review.
(12) No evidence may be offered in support of a motion for reconsideration, except newly discovered evidence that is material for the party moving for reconsideration and that the party could not with reasonable diligence have discovered and produced prior to the final order being issued.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2120, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2120, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-2130
Judicial review of final order.

(1) Judicial review is the process of appealing a final order to a court.
(2) The appellant may appeal a final order by filing a written petition for judicial review that meets the requirements of RCW 34.05.546. The public employees benefits board (PEBB) program may not request judicial review.
(3) The appellant should consult RCW 34.05.510 through 34.05.598 for further details and requirements of the judicial review process.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2130, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-2130

Judicial review of final order.

(1) Judicial review is the process of appealing a final order to a court.
(2) The appellant may appeal a final order by filing a written petition for judicial review that meets the requirements of RCW 34.05.510 through 34.05.598. Neither the public employees benefits board (PEBB) program nor the employing agency may request judicial review.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2130, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2130, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-2140
Presiding officerDesignation and authority.

The designation of a presiding officer shall be consistent with the requirements of RCW 34.05.485 and the presiding officer shall not have personally participated in the decision made by the employing agency or PEBB program.
(1) The presiding officer will decide the issue based on the information provided by the parties during the presiding officer's review of the appeal.
(2) A presiding officer is limited to those powers granted by the state constitution, statutes, rules, or applicable case law.
(3) A presiding officer may not decide that a rule is invalid or unenforceable.
(4) In addition to the record, the presiding officer may employ authority expertise as a basis for the decision.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2140, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-2140

Presiding officerDesignation and authority.

The designation of a presiding officer must be consistent with the requirements of RCW 34.05.485 and the presiding officer must not have personally participated in the decision made by the employing agency or PEBB program.
(1) The presiding officer will decide the issue based on the information provided by the parties during the presiding officer's review of the appeal.
(2) A presiding officer is limited to those powers granted by the state constitution, statutes, rules, or applicable case law.
(3) A presiding officer may not decide that a rule is invalid or unenforceable.
(4) In addition to the record, the presiding officer may employ the authority's expertise as a basis for the decision.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2140, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2140, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-2150
Review officer or officersDesignation and authority.

(1) The designation of a review officer or officers shall be consistent with the requirements of RCW 34.05.491 and the review officer or officers shall not have personally participated in the decision made by the employing agency or PEBB program.
(2) The review officer or officers shall review the initial order and the record to determine if the initial order was correctly decided.
(3) The review officer or officers will issue a final order that will either:
(a) Affirm the initial order in whole or in part;
(b) Reverse the initial order in whole or in part; or
(c) Refer the matter for a formal administrative hearing; or
(d) Remand to the presiding officer in whole or in part.
(4) A review officer or officers are limited to those powers granted by the state constitution, statutes, rules, or applicable case law.
(5) A review officer or officers may not decide that a rule is invalid or unenforceable.
(6) In addition to the record, the review officer or officers may employ authority expertise as a basis for the decision.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2150, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-2150

Review officer or officersDesignation and authority.

(1) The designation of a review officer or officers shall be consistent with the requirements of RCW 34.05.491 and the review officer or officers shall not have personally participated in the decision made by the employing agency or PEBB program.
(2) The review officer or officers shall review the initial order and the record to determine if the initial order was correctly decided.
(3) The review officer or officers will issue a final order that will either:
(a) Affirm the initial order in whole or in part;
(b) Reverse the initial order in whole or in part; or
(c) Refer the matter for a formal administrative hearing; or
(d) Remand to the presiding officer in whole or in part.
(4) A review officer or officers are limited to those powers granted by the state constitution, statutes, rules, or applicable case law.
(5) A review officer or officers may not decide that a rule is invalid or unenforceable.
(6) In addition to the record, the review officer or officers may employ the authority's expertise as a basis for the decision.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2150, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2150, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-2160
Conversion of a brief adjudicative proceeding to a formal administrative hearing.

(1) The presiding officer or the review officer or officers, in their sole discretion may convert a brief adjudicative proceeding to a formal administrative hearing at any time on motion by the subscriber or enrollee or their representative, the authority, or on the presiding officer or review officer or officers' own motion.
(2) The presiding officer or review officer or officers must convert the brief adjudicative proceeding to a formal administrative hearing when it is found that the use of the brief adjudicative proceeding violates any provision of law, when the protection of the public interest requires the authority to give notice and an opportunity to participate to persons other than the parties, or when the issues and interests involved in the controversy warrant the use of the procedures or RCW 34.05.413 through 34.05.479 that govern formal administrative hearings.
(3) When a brief adjudicative proceeding is converted to a formal administrative hearing, the director may become the hearing officer or may designate a replacement hearing officer to conduct the formal administrative hearing upon notice to the subscriber or enrollee and the authority.
(4) When a brief adjudicative proceeding is converted to a formal administrative hearing, WAC 182-16-010 through 182-16-130 and 182-16-3000 through 182-16-3200 apply to the formal administrative hearing.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2160, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-2160

Conversion of a brief adjudicative proceeding to a formal administrative hearing.

(1) The presiding officer or the review officer or officers, in their sole discretion, may convert a brief adjudicative proceeding to a formal administrative hearing at any time on motion by the subscriber or enrollee or their representative, the authority, or on the presiding officer or review officer or officers' own motion.
(2) The presiding officer or review officer or officers must convert the brief adjudicative proceeding to a formal administrative hearing when it is found that the use of the brief adjudicative proceeding violates any provision of law, when the protection of the public interest requires the authority to give notice and an opportunity to participate to persons other than the parties, or when the issues and interests involved in the controversy warrant the use of the procedures or RCW 34.05.413 through 34.05.476 that govern formal administrative hearings.
(3) When a brief adjudicative proceeding is converted to a formal administrative hearing, the director designates a hearing officer to conduct the formal administrative hearing upon notice to the subscriber or enrollee and the authority.
(4) When a brief adjudicative proceeding is converted to a formal administrative hearing, WAC 182-16-010 through 182-16-130 and 182-16-3000 through 182-16-3200 apply to the formal administrative hearing.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-2160, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-2160, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-3000
Formal administrative hearings.

(1) When a brief adjudicative proceeding is converted to a formal administrative hearing consistent with WAC 182-16-2160, the director designates a hearing officer to conduct the formal administrative hearing.
(2) Formal administrative hearings are conducted consistent with the Administrative Procedure Act, RCW 34.05.413 through 34.05.479.
(3) This part describes the general rules and procedures that apply to public employees benefits board (PEBB) benefits formal administrative hearings.
(a) This part supplements the Administrative Procedure Act (APA), chapter 34.05 RCW, and the model rules of procedure in chapter 10-08 WAC. The model rules of procedure adopted by the chief administrative law judge pursuant to RCW 34.05.250, as now or hereafter amended, are hereby adopted for use by the authority in public employees benefits board (PEBB) benefits formal administrative hearings. Other procedural rules adopted in chapters 182-08, 182-12, and 182-16 WAC are supplementary to the model rules of procedure.
(b) In the case of a conflict between the model rules of procedure and this part, the procedural rules adopted in this part shall govern.
(c) If there is a conflict between this part and specific PEBB program rules, the specific PEBB program rules prevail. PEBB program rules are found in chapters 182-08 and 182-12 WAC.
(d) Nothing in this part is intended to affect the constitutional rights of any person or to limit or change additional requirements imposed by statute or other rule. Other laws or rules determine if a hearing right exists, including the APA and program rules or laws.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3000, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-3000

Formal administrative hearings.

(1) When a brief adjudicative proceeding is converted to a formal administrative hearing consistent with WAC 182-16-2160, the director designates a hearing officer to conduct the formal administrative hearing.
(2) Formal administrative hearings are conducted consistent with the Administrative Procedure Act, RCW 34.05.413 through 34.05.476.
(3) Part III describes the general rules and procedures that apply to public employees benefits board (PEBB) benefits formal administrative hearings.
(a) Part III supplements the Administrative Procedure Act (APA), chapter 34.05 RCW, and the model rules of procedure in chapter 10-08 WAC. The model rules of procedure adopted by the chief administrative law judge pursuant to RCW 34.05.250, as now or hereafter amended, are hereby adopted for use by the authority in public employees benefits board (PEBB) benefits formal administrative hearings. Other procedural rules adopted in chapters 182-08, 182-12, and 182-16 WAC are supplementary to the model rules of procedure.
(b) In the case of a conflict between the model rules of procedure and this part, the procedural rules adopted in this part must govern.
(c) If there is a conflict between this part and specific PEBB program rules, the specific PEBB program rules prevail. PEBB program rules are found in chapters 182-08 and 182-12 WAC.
(d) Nothing in this part is intended to affect the constitutional rights of any person or to limit or change additional requirements imposed by statute or other rule. Other laws or rules determine if a hearing right exists, including the APA and program rules or laws.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3000, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3000, filed 10/29/18, effective 1/1/19.]



182-16-3005
RecordFormal administrative hearings.

The record in a formal administrative hearing consists of the official documentation of the hearing process. The record includes, but is not limited to, recordings or transcripts, admitted exhibits, decisions, briefs, notices, orders, and other filed documents.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3005, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-3010
Requirements to appear and represent a party in the formal administrative hearing process.

(1) All parties must provide the hearing officer and all other parties with their name, address, and telephone number.
(2) The appellant may act as their own representative or have another person represent them, except employees of the health care authority (HCA) or HCA's authorized agents.
(3) If the appellant is represented by a person who is not an attorney admitted to practice in Washington state, the representative must provide the hearing officer and all other parties with the representative's name, address, and telephone number. In cases involving confidential information, the nonattorney representative must provide the HCA hearing representative with a signed, written consent permitting release to the nonattorney representative of personal health information protected by state or federal law.
(4) An attorney admitted to practice law in Washington state, who wishes to represent the appellant, must file a written notice of appearance containing the attorney's name, address, and telephone number with the hearing officer's office and serve all parties with the notice. In cases involving confidential information, the attorney representative must provide the HCA hearing representative with a signed, written consent permitting release to the attorney representative of the appellant's personal health information protected by state or federal law. If the appellant's attorney representative no longer represents the appellant, then the attorney must file a written notice of withdrawal of representation with the hearing officer's office and serve all parties with the notice.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3010, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-3010

Requirements to appear and represent a party in the formal administrative hearing process.

(1) All parties must provide the hearing officer and all other parties with their name, address, and telephone number.
(2) The appellant may act as their own representative or have another person represent them, except that employees of the health care authority (HCA) or HCA's authorized agents may not represent an appellant, unless approved by a hearing officer.
(3) If the appellant is represented by a person who is not an attorney admitted to practice in Washington state, the representative must provide the hearing officer and all other parties with the representative's name, address, and telephone number. In cases involving confidential information, the nonattorney representative must provide the HCA hearing representative with a signed, written consent permitting release to the nonattorney representative of health information protected by state or federal law.
(4) An attorney admitted to practice law in Washington state, who wishes to represent the appellant, must file a written notice of appearance containing the attorney's name, address, and telephone number with the hearing officer's office and serve all parties with the notice. In cases involving confidential information, the attorney representative must provide the HCA hearing representative with a signed, written consent permitting release to the attorney representative of the appellant's health information protected by state or federal law. If the appellant's attorney representative no longer represents the appellant, then the attorney must file a written notice of withdrawal of representation with the hearing officer's office and serve all parties with the notice.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3010, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3010, filed 10/29/18, effective 1/1/19.]



182-16-3015
Hearing officersAssignment, motions of prejudice, and disqualification.

(1) Assignment. A hearing officer will be assigned at least five business days before a hearing. A party may ask which hearing officer is assigned to a hearing by contacting the hearing officer's office listed on the notice of hearing. If requested by a party, the hearing officer's office must send the name of the assigned hearing officer to all parties, by electronic mail or in writing, at least five business days before the scheduled hearing date.
(2) Motion of prejudice. Any party requesting a different hearing officer may file a written motion of prejudice against the hearing officer assigned to the matter before the hearing officer rules on a discretionary issue in the case, admits evidence, or takes testimony.
(a) A motion of prejudice must include a declaration stating that a party does not believe the hearing officer can hear the case fairly. Service of copies of the motion must also be made to all parties listed on the notice of hearing.
(b) Any party's first motion of prejudice will be automatically granted. Any subsequent motion of prejudice made by a party may be granted or denied at the discretion of the hearing officer no later than seven days after receiving the motion.
(c) A party may make an oral motion of prejudice at the beginning of a hearing before the hearing officer rules on a discretionary issue in the matter, admits evidence, or takes testimony if:
(i) The hearing officer was not assigned at least five business days before the date of the hearing; or
(ii) The hearing officer was changed within five business days of the date of the hearing.
(3) Disqualification. A hearing officer may be disqualified from presiding over a hearing for bias, prejudice, conflict of interest, or ex parte contact with a party to the hearing.
(a) Any party may file a petition to disqualify a hearing officer as described in RCW 34.05.425. A petition to disqualify must be in writing and service promptly made to all parties and the hearing officer upon discovering facts of possible grounds for disqualification.
(b) The hearing officer whose disqualification is requested will determine whether to grant or deny the petition in a written order, stating facts and reasons for the determination. The hearing officer must serve the order no later than seven days after receiving the petition for disqualification.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3015, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-3030
Authority of the hearing officer.

(1) A hearing officer must hear and decide the issues de novo (anew) based on the evidence and oral or written arguments presented during a formal administrative hearing and admitted into the record.
(2) A hearing officer has no inherent or common law powers, and is limited to those powers granted by the state constitution, statutes, or rules.
(3) A hearing officer may not decide that a rule is invalid or unenforceable. If the validity of a rule is raised during a formal administrative hearing, the hearing officer may allow only argument to preserve the record for judicial review.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3030, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-3030

Authority of the hearing officer.

(1) A hearing officer must hear and decide the issues based on the evidence and oral or written arguments presented during a formal administrative hearing and admitted into the record.
(2) A hearing officer has no inherent or common law powers, and is limited to those powers granted by the state constitution, statutes, or rules.
(3) A hearing officer may not decide that a rule is invalid or unenforceable. If the validity of a rule is raised during a formal administrative hearing, the hearing officer may allow only argument to preserve the record for judicial review.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3030, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3030, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-3080
Time requirements for service of notices made by the hearing officer.

(1) The hearing officer or their designee must serve a notice of a formal administrative hearing to all parties and their representatives at least twenty-one calendar days before the hearing date. The parties may agree to, but the hearing officer cannot impose, a shorter notice period.
(2) If a prehearing conference or dispositive motion hearing is scheduled, the hearing officer must serve a notice of the prehearing conference or dispositive motion hearing to the parties and their representatives at least seven business days before the date of the prehearing conference or dispositive motion hearing except:
(a) The hearing officer may change any scheduled formal administrative hearing into a prehearing conference or dispositive motion hearing and provide less than seven business days' notice of the prehearing conference or dispositive motion hearing; and
(b) The hearing officer may give less than seven business days' notice if the only purpose of the prehearing conference is to consider whether to grant a continuance.
(3) The hearing officer must reschedule a formal administrative hearing if necessary to comply with the notice requirements in this section.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3080, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-3080

Time requirements for service of notices made by the hearing officer.

(1) The hearing officer or their designee must serve a notice of a formal administrative hearing to all parties and their representatives at least twenty-one calendar days before the hearing date. The parties may agree to, but the hearing officer cannot impose, a shorter notice period.
(2) If a prehearing conference or dispositive motion hearing is scheduled, the hearing officer must serve a notice of the prehearing conference or dispositive motion hearing to the parties and their representatives at least seven business days before the date of the prehearing conference or dispositive motion hearing except:
(a) The hearing officer may change any scheduled formal administrative hearing into a prehearing conference or dispositive motion hearing and provide less than seven business days' notice of the prehearing conference or dispositive motion hearing; and
(b) The hearing officer may give less than seven business days' notice if the only purpose of the prehearing conference is to consider whether to grant a continuance.
(3) The hearing officer must reschedule a formal administrative hearing if necessary to comply with the notice requirements in Part III of this chapter.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3080, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3080, filed 10/29/18, effective 1/1/19.]



182-16-3090
Formal administrative hearing location.

(1) A hearing officer must be present at all hearings. Hearings may be held either in person or telephonically.
(a) A telephonic hearing is where all parties and the hearing officer are present by telephone.
(b) An in-person hearing is where the appellant appears face-to-face with the hearing officer. The other parties can choose to appear either in person or by telephone, but cannot be ordered to appear in person.
(2) Whether a hearing is held in person or telephonically, the parties have the right to see all documents, hear all testimony, and question all witnesses.
(3) If a hearing is originally scheduled to be held in person, the appellant may ask the hearing officer to change the in-person hearing to a telephonic hearing. Once a telephonic hearing begins, the hearing officer may stop, reschedule, and change the telephonic hearing to an in-person hearing if any party makes such a request.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3090, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-3100
Rescheduling and continuances for formal administrative hearings.

(1) Any party may request the hearing officer to reschedule a formal administrative hearing if a rule requires notice of a hearing and the amount of notice required was not provided.
(a) The hearing officer must reschedule the hearing under circumstances identified in subsection (1) of this section if requested by any party.
(b) The parties may agree to shorten the amount of notice required by any rule.
(2) Any party may request a continuance of a formal administrative hearing either orally or in writing.
(a) In each formal administrative hearing, the hearing officer must grant each party's first request for a continuance. The continuance may be up to thirty calendar days.
(b) The hearing officer may grant each party up to one additional continuance of up to thirty calendar days because of extraordinary circumstances established at a proceeding.
(c) After granting a continuance, the hearing officer or their designee must:
(i) Immediately telephone all other parties to inform them the hearing was continued; and
(ii) Serve an order of continuance on the parties no later than fourteen days before the new formal administrative hearing date. All orders of continuance must provide a new deadline for filing documents with the hearing officer. The new filing deadline can be no less than ten calendar days prior to the new formal administrative hearing date. If the continuance is granted pursuant to (b) of this subsection, then the order of continuance must also include findings of fact that state with specificity the extraordinary circumstances for which the hearing officer granted the continuance.
(3) Regardless of whether a party has been granted a continuance as described in subsection (1) of this section, the hearing officer must grant a continuance if a new material issue is raised during the formal administrative hearing and a party requests a continuance.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3100, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-3100

Rescheduling and continuances for formal administrative hearings.

(1) Any party may request the hearing officer to reschedule a formal administrative hearing if a rule requires notice of a hearing and the amount of notice required was not provided.
(a) The hearing officer must reschedule the hearing under circumstances identified in this chapter if requested by any party.
(b) The parties may agree to shorten the amount of notice required by any rule.
(2) Any party may request a continuance of a formal administrative hearing either orally or in writing.
(a) In each formal administrative hearing, the hearing officer must grant each party's first request for a continuance. The continuance may be up to thirty calendar days.
(b) The hearing officer may grant each party up to one additional continuance of up to thirty calendar days because of extraordinary circumstances.
(c) After granting a continuance, the hearing officer or their designee must:
(i) Immediately telephone all other parties to inform them the hearing was continued; and
(ii) Serve an order of continuance on the parties no later than fourteen days before the new formal administrative hearing date. All orders of continuance must provide a new deadline for filing documents with the hearing officer. The new filing deadline can be no less than ten calendar days prior to the new formal administrative hearing date. If the continuance is granted pursuant to (b) of this subsection, then the order of continuance must also include findings of fact that state with specificity the extraordinary circumstances for which the hearing officer granted the continuance.
(3) Regardless of whether a party has been granted a continuance as described in subsection (2)(b) of this section, the hearing officer must grant a continuance if a new material issue is raised during the formal administrative hearing and a party requests a continuance.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3100, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3100, filed 10/29/18, effective 1/1/19.]



182-16-3110
Prehearing conferences.

(1) A prehearing conference is a formal proceeding conducted on the record by a hearing officer to prepare for a formal administrative hearing.
(a) The hearing officer must record a prehearing conference using audio recording equipment.
(b) The hearing officer may conduct a prehearing conference in person, by telephone conference call, or in any other manner acceptable to the parties.
(2) Any party can request a prehearing conference. The hearing officer must grant each party's first request for a prehearing conference if it is filed with the hearing officer at least seven business days before the next scheduled hearing date. The hearing officer may grant requests for additional prehearing conferences.
(3) The appellant must attend or participate in any scheduled prehearing conference. If the appellant does not attend or participate in a scheduled prehearing conference, the hearing officer will enter an order of default dismissing the matter.
(4) During a prehearing conference the parties and the hearing officer may:
(a) Identify the issue or issues to be decided;
(b) Agree to the date, time, and place of any requested or necessary hearing or hearings;
(c) Identify accommodation and safety issues; or
(d) Establish a schedule for:
(i) The exchange and filing of briefs;
(ii) Providing a list of proposed witnesses;
(iii) Providing exhibit lists; and
(iv) Providing proposed exhibits before the hearing.
(5) After the prehearing conference ends, the hearing officer must enter a written order that recites the action taken at the prehearing conference, a case schedule outlining hearing dates and deadlines for exchanging witness lists and exhibits, and any other agreements reached by the parties.
(6) The hearing officer must serve the prehearing order to the parties at least fourteen calendar days before the next scheduled hearing.
(7) A party may object to the prehearing order by filing an objection with the hearing officer in writing no later than ten days after the service date of the order. The hearing officer must serve a written ruling on the objection.
(8) If no objection is made to the prehearing order, the order determines how the case will be conducted by the hearing officer, including whether a hearing will be in person or held by telephone conference, unless the hearing officer enters an amended prehearing conference order.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3110, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-3120
Dispositive motions.

(1) A dispositive motion could dispose of one or all the issues in a formal administrative hearing, such as a motion to dismiss or motion for summary judgment.
(2) To request a dispositive motion hearing a party must file a written dispositive motion with the hearing officer and serve a copy of the motion to all other parties. The hearing officer may also set a dispositive motion hearing, and request briefing from the parties, to address any possible dispositive issues the hearing officer believes must be addressed before the hearing.
(3) The deadline to file a timely dispositive motion shall be ten calendar days before the scheduled hearing.
(4) Upon receiving a dispositive motion, a hearing officer:
(a) Must convert the scheduled hearing to a dispositive motion hearing when:
(i) The dispositive motion is timely filed with the hearing officer at least ten calendar days before the date of the hearing; and
(ii) The party filing the dispositive motion has not previously filed a dispositive motion.
(b) May schedule a dispositive motion hearing in all instances other than described in (a) of this subsection.
(5) The hearing officer may conduct the dispositive motion hearing in person or by telephone conference. For dispositive motion hearings scheduled to be held in person, the HCA hearing representative may choose to attend and participate in person or by telephone conference call.
(6) The party requesting the dispositive motion hearing must attend and participate in the dispositive motion hearing in person or by telephone. If the party requesting the motion hearing does not attend and participate in the dispositive motion hearing, the hearing officer will enter an order of default.
(7) During a dispositive motion hearing, the hearing officer can only consider the filed dispositive motions, any response to the motions, evidence submitted to support or oppose the motions, and argument on the motions. Prior to rescheduling any necessary hearings, the hearing officer must serve a written order on the dispositive motions.
(8) The hearing officer must serve the written order on the dispositive motions to all parties no later than eighteen calendar days after the dispositive motion hearing is held. Orders on dispositive motions are subject to motions for reconsideration or petitions for judicial review as described in WAC 182-16-2120 and 182-16-2130.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3120, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-3120

Dispositive motions.

(1) A dispositive motion could dispose of one or all the issues in a formal administrative hearing, such as a motion to dismiss or motion for summary judgment.
(2) To request a dispositive motion hearing a party must file a written dispositive motion with the hearing officer and serve a copy of the motion to all other parties. The hearing officer may also set a dispositive motion hearing, and request briefing from the parties, to address any possible dispositive issues the hearing officer believes must be addressed before the hearing.
(3) The deadline to file a timely dispositive motion must be ten calendar days before the scheduled hearing.
(4) Upon receiving a dispositive motion, a hearing officer:
(a) Must convert the scheduled hearing to a dispositive motion hearing when:
(i) The dispositive motion is timely filed with the hearing officer at least ten calendar days before the date of the hearing; and
(ii) The party filing the dispositive motion has not previously filed a dispositive motion.
(b) May schedule a dispositive motion hearing in all instances other than described in (a) of this subsection.
(5) The hearing officer may conduct the dispositive motion hearing in person or by telephone conference. For dispositive motion hearings scheduled to be held in person, the HCA hearing representative may choose to attend and participate in person or by telephone conference call.
(6) The party requesting the dispositive motion hearing must attend and participate in the dispositive motion hearing in person or by telephone. If the party requesting the motion hearing does not attend and participate in the dispositive motion hearing, the hearing officer will enter an order dismissing the dispositive motion.
(7) During a dispositive motion hearing, the hearing officer can only consider the filed dispositive motions, any response to the motions, evidence submitted to support or oppose the motions, and argument on the motions. Prior to rescheduling any necessary hearings, the hearing officer must serve a written order on the dispositive motions.
(8) The hearing officer must serve the written order on the dispositive motions to all parties no later than eighteen calendar days after the dispositive motion hearing is held. Orders on dispositive motions are subject to motions for reconsideration or petitions for judicial review as described in WAC 182-16-2120 and 182-16-2130.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3120, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3120, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-3130
Subpoenas.

(1) Hearing officers, the HCA hearing representative, and attorneys for the parties may prepare subpoenas as described in Washington state civil rule 45, unless otherwise prohibited by law. Any party may request the hearing officer prepare a subpoena on their behalf.
(2) The hearing officer may schedule a prehearing conference to decide whether to issue a subpoena.
(3) If a party requests the hearing officer prepare a subpoena on its behalf, the party is responsible for:
(a) Service of the subpoena; and
(b) Any costs associated with:
(i) Compliance with the subpoena; and
(ii) Witness fees as described in RCW 34.05.446(7).
(4) Service of a subpoena must be made by a person who is at least eighteen years old and not a party to the hearing. Service of the subpoena is complete when the person serving the subpoena:
(a) Gives the person or entity named in the subpoena a copy of the subpoena; or
(b) Leaves a copy of the subpoena with a person over the age of eighteen at the residence or place of business of the person or entity named in the subpoena.
(5) To prove service of a subpoena on a witness, the person serving the subpoena must file with the hearing officer's office a signed, written, and dated statement that includes:
(a) The name of the person to whom service of the subpoena occurred;
(b) The date the service of the subpoena occurred;
(c) The address where the service of the subpoena occurred; and
(d) The name, age, and address of the person who provided service of the subpoena.
(6) A party may request the hearing officer quash (set aside) or change a subpoena request at any time before the deadline given in the subpoena.
(7) A hearing officer may quash (set aside) or change a subpoena if it is unreasonable.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3130, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-3130

Subpoenas.

(1) Hearing officers, the HCA hearing representative, and attorneys for the parties may prepare subpoenas as described in Washington state civil rule 45, unless otherwise prohibited by law. Any party may request the hearing officer prepare a subpoena on their behalf.
(2) The hearing officer may schedule a prehearing conference to decide whether to issue a subpoena.
(3) If a party requests the hearing officer prepare a subpoena on its behalf, the party is responsible for:
(a) Service of the subpoena; and
(b) Any costs associated with:
(i) Compliance with the subpoena; and
(ii) Witness fees as described in RCW 34.05.446(7).
(4) Service of a subpoena must be made by a person who is at least eighteen years old and not a party to the hearing. Service of the subpoena is complete when the person serving the subpoena:
(a) Gives the person or entity named in the subpoena a copy of the subpoena; or
(b) Leaves a copy of the subpoena with a person over the age of eighteen at the residence or place of business of the person or entity named in the subpoena.
(5) To prove service of a subpoena on a witness, the person serving the subpoena must file with the hearing officer's office a signed, written, and dated statement that includes:
(a) The name of the person to whom service of the subpoena occurred;
(b) The date the service of the subpoena occurred;
(c) The address where the service of the subpoena occurred; and
(d) The name, age, and address of the person who provided service of the subpoena.
(6) A person or entity subject to or affected by the subpoena may request the hearing officer quash (set aside) or change a subpoena request at any time before the deadline given in the subpoena.
(7) A hearing officer may quash (set aside) or change a subpoena if it is unreasonable.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3130, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3130, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-3140
Orders of dismissalReinstating a formal administrative hearing after an order of dismissal.

(1) An order of dismissal is an order from the hearing officer ending the matter. The order is entered because the party who made the appeal withdrew from the proceeding, the appellant is no longer aggrieved, the hearing officer granted a dispositive motion dismissing the matter, or the hearing officer entered an order of default because the party who made the appeal failed to attend or refused to participate in a prehearing conference or the formal administrative hearing.
(2) The order of dismissal becomes a final order if no party files a request to vacate the order as described in subsections (3) through (7) of this section.
(3) If the hearing officer enters and serves an order dismissing the formal administrative hearing, the appellant may file a written request to vacate (set aside) the order of dismissal. Upon receipt of a request to vacate an order of dismissal, the hearing officer must schedule and serve notice of a prehearing conference as described in WAC 182-16-3080. At the prehearing conference, the party asking that the order of dismissal be vacated has the burden to show good cause according to subsection (8) of this section for an order of dismissal to be vacated and the matter to be reinstated.
(4) The request to vacate an order of dismissal must be filed with the hearing officer and the other parties. The party requesting that an order of dismissal be vacated should specify in the request why the order of dismissal should be vacated.
(5) The request to vacate an order of dismissal must be filed with the hearing officer no later than twenty-one calendar days after the date the order of dismissal was entered. If no request is received within that deadline, the dismissal order becomes a final order and the final order will stand.
(6) If the hearing officer finds good cause, as described in subsection (8) of this section, for the order of dismissal to be vacated, the hearing officer must enter and serve a written order to the parties setting forth the findings of fact, conclusions of law, and reinstatement of the matter.
(7) If the order of dismissal is vacated, the hearing officer will conduct a formal administrative hearing at which the parties may present argument and evidence about issues raised in the original appeal. The formal administrative hearing may occur immediately following the prehearing conference on the request to vacate only if agreed to by the parties and the hearing officer, otherwise a formal administrative hearing date must be scheduled by the hearing officer.
(8) Good cause is a substantial reason or legal justification for failing to appear, act, or respond to an action using the provisions of Superior Court civil rule 60 as a guideline. This good cause exception applies only to this chapter. This good cause exception does not apply to any other chapter or chapters in Title 182 WAC.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3140, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-3140

Orders of dismissalReinstating a formal administrative hearing after an order of dismissal.

(1) An order of dismissal is an order from the hearing officer ending the matter. The order is entered because the party who made the appeal withdrew from the proceeding, the appellant is no longer aggrieved, the hearing officer granted a dispositive motion dismissing the matter, or the hearing officer entered an order of default because the party who made the appeal failed to attend or refused to participate in a prehearing conference or the formal administrative hearing.
(2) The order of dismissal becomes a final order if no party files a request to vacate the order as described in subsections (3) through (7) of this section.
(3) If the hearing officer enters and serves an order dismissing the formal administrative hearing, the appellant may file a written request to vacate (set aside) the order of dismissal. Upon receipt of a request to vacate an order of dismissal, the hearing officer must schedule and serve notice of a prehearing conference as described in WAC 182-16-3080. At the prehearing conference, the party asking that the order of dismissal be vacated has the burden to show good cause according to subsection (8) of this section for an order of dismissal to be vacated and the matter to be reinstated.
(4) The request to vacate an order of dismissal must be filed with the hearing officer and the other parties. The party requesting that an order of dismissal be vacated should specify in the request why the order of dismissal should be vacated.
(5) The request to vacate an order of dismissal must be filed with the hearing officer no later than twenty-one calendar days after the date the order of dismissal was entered. If no request is received within that deadline, the dismissal order becomes the health care authority's final decision without further action.
(6) If the hearing officer finds good cause, as described in subsection (8) of this section, for the order of dismissal to be vacated, the hearing officer must enter and serve a written order to the parties setting forth the findings of fact, conclusions of law, and reinstatement of the matter.
(7) If the order of dismissal is vacated, the hearing officer will conduct a formal administrative hearing at which the parties may present argument and evidence about issues raised in the original appeal. The formal administrative hearing may occur immediately following the prehearing conference on the request to vacate only if agreed to by the parties and the hearing officer, otherwise a formal administrative hearing date must be scheduled by the hearing officer.
(8) Good cause is a substantial reason or legal justification for failing to appear, act, or respond to an action using the provisions of Superior Court civil rule 60 as a guideline. This good cause exception applies only to this chapter. This good cause exception does not apply to any other chapter or chapters in Title 182 WAC.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3140, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3140, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-3160
Withdrawing a formal administrative hearing.

(1) The appellant may withdraw a formal administrative hearing for any reason, and at any time, by contacting the HCA hearing representative who will coordinate the withdrawal with the hearing officer.
(2) The request for withdrawal must generally be made in writing. An oral withdrawal by the appellant is permitted during a formal administrative hearing when both the hearing officer and HCA hearing representative are present.
(3) After a withdrawal request is received, the hearing officer must cancel any scheduled hearings and enter and serve a written order dismissing the case.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3160, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-3160

Withdrawing a formal administrative hearing.

(1) The appellant may withdraw a formal administrative hearing for any reason, and at any time, by contacting the health care authority (HCA) hearing representative who will coordinate the withdrawal with the hearing officer.
(2) The request for withdrawal must generally be made in writing. An oral withdrawal by the appellant is permitted during a formal administrative hearing when both the hearing officer and HCA hearing representative are present.
(3) After a withdrawal request is received, the hearing officer must cancel any scheduled hearings and enter and serve a written order dismissing the case.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3160, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3160, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-3170
Final order deadlineRequired information.

(1) Within ninety days after the formal administrative hearing record is closed, the hearing officer shall serve a final order that shall be the final decision of the authority. The hearing officer shall serve a copy of the final order to all parties.
(2) The hearing officer must include the following information in the written final order:
(a) Identify the order as a final order of the public employees benefits board (PEBB) program;
(b) List the name and docket number of the case and the names of all parties and representatives;
(c) Enter findings of fact used to resolve the dispute based on the evidence admitted in the record;
(d) Explain why evidence is, or is not, credible when describing the weight given to evidence related to disputed facts;
(e) State the law that applies to the dispute;
(f) Apply the law to the facts of the case in the conclusions of law;
(g) Discuss the reasons for the decision based on the facts and the law;
(h) State the result and remedy ordered; and
(i) Include any other information required by law or program rules.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3170, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-3170

Final order deadlineRequired information.

(1) Within ninety days after the formal administrative hearing record is closed, the hearing officer must serve a final order that must be the final decision of the authority. The hearing officer shall serve a copy of the final order to all parties.
(2) The hearing officer must include the following information in the written final order:
(a) Identify the order as a final order of the public employees benefits board (PEBB) program;
(b) List the name and docket number of the case and the names of all parties and representatives;
(c) Enter findings of fact used to resolve the dispute based on the evidence admitted in the record;
(d) Explain why evidence is, or is not, credible when describing the weight given to evidence related to disputed facts;
(e) State the law that applies to the dispute;
(f) Apply the law to the facts of the case in the conclusions of law;
(g) Discuss the reasons for the decision based on the facts and the law;
(h) State the result and remedy ordered; and
(i) Include any other information required by law or program rules.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3170, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3170, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-3180
Request for reconsideration and responseProcess.

(1) A request for reconsideration asks the hearing officer to reconsider the final order because the party believes the hearing officer made a mistake of law, mistake of fact, or clerical error.
(2) A request for reconsideration must state in writing why the party wants the final order to be reconsidered.
(3) Requests for reconsideration must be filed with the hearing officer who entered the final order.
(4) If a party files a request for reconsideration:
(a) The hearing officer must receive the request for reconsideration on or before the tenth business day after the service date of the final order.
(b) The party filing the request must serve copies of the request to all other parties.
(c) Within five business days of receiving a request for reconsideration, the hearing officer must serve to all parties a notice that provides the date the request for reconsideration was received.
(5) The other parties may respond to the request for reconsideration. The response must state in writing why the final order should stand. Responses are optional. If a party chooses not to respond, that party will not be prejudiced because of that choice.
(a) Responses to a request for reconsideration must be received by the hearing officer no later than seven business days after the service date of the hearing officer's notice as described in subsection (4)(c) of this section, or the response will not be considered.
(b) Service of responses to a request for reconsideration must be made to all parties.
(6) If a party needs more time to file a request for reconsideration or respond to a request for reconsideration, the hearing officer may extend the required time frame if the party makes a written request providing a good reason for the request within the required time frame.
(7) No evidence may be offered in support of a motion for re-consideration, except newly discovered evidence that is material for the party moving for reconsideration and that the party could not with reasonable diligence have discovered and produced at the hearing or before the ruling on a dispositive motion.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3180, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-3180

Request for reconsideration and responseProcess.

(1) A request for reconsideration asks the hearing officer to reconsider the final order because the party believes the hearing officer made a mistake of law, mistake of fact, or clerical error.
(2) A request for reconsideration must state in writing why the party wants the final order to be reconsidered.
(3) Requests for reconsideration must be filed with the hearing officer who entered the final order.
(4) If a party files a request for reconsideration:
(a) The hearing officer must receive the request for reconsideration on or before the tenth business day after the service date of the final order;
(b) The party filing the request must serve copies of the request on all other parties on the same day the request is served on the hearing officer; and
(c) Within five business days of receiving a request for reconsideration, the hearing officer must serve to all parties a notice that provides the date the request for reconsideration was received.
(5) The other parties may respond to the request for reconsideration. The response must state in writing why the final order should stand. Responses are optional. If a party chooses not to respond, that party will not be prejudiced because of that choice.
(a) Responses to a request for reconsideration must be received by the hearing officer no later than seven business days after the service date of the hearing officer's notice as described in subsection (4)(c) of this section, or the response will not be considered.
(b) Service of responses to a request for reconsideration must be made to all parties.
(6) If a party needs more time to file a request for reconsideration or respond to a request for reconsideration, the hearing officer may extend the required time frame if the party makes a written request providing a good reason for the request within the required time frame.
(7) No evidence may be offered in support of a motion for re-consideration, except newly discovered evidence that is material for the party moving for reconsideration and that the party could not have reasonably discovered and produced at the hearing or before the ruling on a dispositive motion.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3180, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3180, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-3190
Decisions on requests for reconsideration.

(1) Unless the request for reconsideration is denied as untimely filed under WAC 182-16-3180, the same hearing officer who entered the final order, if reasonably available, will also dispose of the request as well as any responses received.
(2) The decision on the request for reconsideration must be in the form of a written order denying or granting the request in whole or in part and issuing a new written final order.
(3) If the hearing officer does not send an order on the request for reconsideration within twenty calendar days of the date of the notice described in WAC 182-16-2120, the request is deemed denied.
(4) If any party files a request for reconsideration of the final order, the reconsideration process must be completed before any judicial review may be requested. However, the filing of a request for reconsideration is not required before requesting judicial review.
(5) An order denying a request for reconsideration is not subject to judicial review.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3190, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-3190

Decisions on requests for reconsideration.

(1) Unless the request for reconsideration is denied as untimely filed under WAC 182-16-3180, the same hearing officer who entered the final order, if reasonably available, will also dispose of the request as well as any responses received.
(2) The decision on the request for reconsideration must be in the form of a written order denying or granting the request in whole or in part and if the request is granted issuing a new written final order.
(3) If the hearing officer does not send an order on the request for reconsideration within twenty calendar days of the date of the notice described in WAC 182-16-3180 (4)(c), the request is deemed denied.
(4) If any party files a request for reconsideration of the final order, the reconsideration process must be completed before any judicial review may be requested. However, the filing of a request for reconsideration is not required before requesting judicial review.
(5) An order denying a request for reconsideration is not subject to judicial review.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3190, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3190, filed 10/29/18, effective 1/1/19.]



(Effective until January 1, 2020)

182-16-3200
Judicial review of final order.

(1) Judicial review is the process of appealing a final order to a court.
(2) The appellant may appeal a final order by filing a written petition for judicial review that meets the requirements of RCW 34.05.546. The public employees benefits board (PEBB) program may not request judicial review.
(3) The appellant should consult RCW 34.05.510 through 34.05.598 for further details and requirements of the judicial review process.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3200, filed 10/29/18, effective 1/1/19.]
(Effective January 1, 2020)

182-16-3200

Judicial review of final order.

(1) Judicial review is the process of appealing a final order to a court.
(2) The appellant may appeal a final order by filing a written petition for judicial review that meets the requirements of RCW 34.05.510 through 34.05.598. The public employees benefits board (PEBB) program may not request judicial review.
(3) The appellant should consult RCW 34.05.510 through 34.05.598 for further details and requirements of the judicial review process.
[Statutory Authority: RCW 41.05.021, 41.05.160, and PEBB policy resolutions. WSR 19-17-073 (Admin #2019-01), § 182-16-3200, filed 8/20/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-033 (Admin #2018-03), § 182-16-3200, filed 10/29/18, effective 1/1/19.]