How to appeal an eligibilty denial

If you and/or a dependent are denied coverage under the plan, you have the right to appeal to the PEBTF.

Submit you appeal: You must submit your appeal, in writing, by completing the required Appeal Request Form within 180 days of the date you receive notice that your eligibility has been terminated. Complete the Appeal Request Form and return it to the PEBTF by email, fax or mail (information may be found on the form).

Receive decision: Within 60 days of receipt of your appeal, the Board of Trustees (for Active members) or the Commonwealth (for Retiree members) will review your appeal and send you, in writing, a final decision or request for additional information.

How to appeal a denied claim

If your claim for benefits under the medical plan, mental health and substance use program or supplemental benefits (vision, dental and hearing aid) is denied, the claims payor will advise you in writing of the denial, the reason(s) for it and the procedures for appealing a denied claim.

Your appeal must be made in writing to the claims payor within 180 days after you receive notice that your claim has been denied (may take the form of an Explanation of Benefits). Please contact the claims payor for instructions.

Final appeal process: If you are not satisfied with the claims payor’s decision on appeal, you have the right to appeal to the Board of Trustees (Active members) or the Commonwealth (Retiree members) by completing the required Appeal Request Form and returning it to the PEBTF by email, fax or mail (information may be found on the form). NOTE: The PEBTF will not review an appeal if it is subject to a specific exclusion under the PEBTF’s/REHP’s Plan of Benefits. Your appeal must be postmarked or actually received (if sent by other than U.S. Mail First Class) within 30 days of receipt of the claims payor’s final decision.

Receive decision Within 60 days of receipt of your appeal, the Board of Trustees (for Active members) or the Commonwealth (for Retiree members) will review your appeal and send you, in writing, a final decision or request for additional information. There may be special circumstances where the Trustees need additional time to review your appeal and gather additional information. The PEBTF will contact you if additional time is needed.

How to appeal a Get Healthy waiver denial

If you received a letter stating that you did not fulfill the obligations under the Get Healthy Program and you did not receive the contribution waiver, you have the right to appeal, in writing, to the PEBTF.

Submit your appeal: Submit your appeal, in writing, within 30 days after you receive the Get Healthy letter. Complete the required Appeal Request Form and return it to the PEBTF by email, fax or mail (information may be found on the form).

Receive decision The Board of Trustees will review your appeal, including such other pertinent information you may present, and will notify you of its decision within 60 days of the date of the appeal.

Expedited Appeals Process

The PEBTF offers an expedited appeal process where an expedited review is medically necessary to secure prompt and appropriate medical treatment.

Where the PEBTF is authorized to review appeals, the Executive Director of the PEBTF, in consultation with such PEBTF staff as the Executive Director deems appropriate may, in their sole discretion, submit an appeal for expedited review to the Board of Trustees (Active members) or the Commonwealth (Retiree members). A decision will be made within 72 hours of the PEBTF’s receipt of appeal.

Independent review

If your claim is still denied after your appeal, you may be able to have an independent party review your denied claim. You may find more information on independent reviews in the Summary Plan Description (Active members) or the REHP Benefits Handbook (Retiree members).