Washington Administrative Code
Title 182 - Health Care Authority
PUBLIC EMPLOYEES BENEFITS BOARD (PEBB) PROGRAM
Chapter 182-16 - Appeals practice and procedure
Part I - GENERAL PROVISIONS
Section 182-16-040 - What should the request for review or notice of appeal contain?

(1) The name and mailing address of the party submitting the request for review or notice of appeal;

(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 and substantiates why the decision should be reversed. Information or documentation submitted at a later date, unless specifically requested by the PEBB appeals manager, may not be considered in the appeal decision;

(7) The type of relief sought;

(8) A statement that the appealing party has read the notice of appeal and believes the contents to be true and correct; and

(9) The signature of the appealing party or the appealing party's representative.