SEBB appeals status update

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SEBB appeals status update

Since early December, HCA has received a high volume of appeals for the SEBB Program. HCA’s team that handles appeals typically has seven to eight staff. Given the volume of appeals received, we have tripled the number of individuals supporting the appeals process. HCA will continue evaluating and adding more resources as needed.

Of the approximately 150,000 school employees and 185,000 dependents, there are four primary types of appeals being received:

  1. Dependent verification: Over half of the appeals are related to dependent verification denials.
  2. Dental plans: Over 1,000 appeals are related to dental plan confusion between the two dental plans administered by Delta Dental.
  3. Automatic plan enrollment: Several hundred appeals relate to the way HCA reconciled incomplete or unclear enrollment information in SEBB My Account.
  4. Inconsistencies in plan enrollment: Several dozen appeals concern inconsistencies with plan enrollments that appear on a confirmation letter.

Immediate actions

You can assure your employees who submitted an appeal that HCA is working through the appeals as quickly as possible.

This week, HCA will begin mailing letters to school employees whose appeals have been processed. The letter will state either:

  • The employee’s appeal was approved.
  • Information about next steps in the appeals process.

HCA has been updating eligibility and enrollment related to successful appeals in our system of record before communicating the results of the appeal to the school employee. Daily carrier enrollment files include the coverage updates, and in urgent and emergency situations the coverage exists even if the member is not yet aware of it.

How to check if an appeal has been received or request an expedited appeal for an urgent medical need

If your employee feels their or their dependent’s life, health, or safety is at risk, you should advise them to seek care immediately.

Effective immediately, employees can call 1-800-200-1004 (and select menu option 7) 8 a.m. to 4:30 p.m. Monday through Friday to:

  • Learn whether we have received their appeal.
  • Request to expedite review of their appeal if the employee or their dependent has an urgent medical need.

Please keep in mind that call wait times may be longer than usual due to the high volume of appeals. Until all appeals are logged in, our records may not show their appeal as being received yet. Our goal is to process all approved appeals that do not need additional action by a school employee by mid-January. Employees should not resubmit their appeals until all appeals have been processed.

An urgent medical need for physical health, mental health, and substance use disorder services may include:

  • Urgent care or emergency care visits.
  • Hospital admissions.
  • A surgery or procedure needed within the next 10 calendar days.
  • A medication refill needed within the next 10 calendar days.

When they call, they should tell the customer service representative that they or their dependent have an urgent medical need requiring an expedited appeal decision. An HCA account manager will contact you by phone or email (generally the same day but within one business day) and work with you until a resolution on the appeal is reached. If the situation occurs outside of HCA business hours, contact HCA the following business day.

Timeline

By January 15, HCA’s goal is to fully process approved appeals that do not need additional action by a school employee. This timeline will allow the largest enrollment changes to be reflected in the next billing invoice that will be prepared for SEBB organizations on January 15. Until then, we are telling employees that, although our records do not show their appeal as being received yet, that doesn’t mean we don’t have it. We are still working through them with the goal of getting them processed by January 15. Please encourage employees not to resubmit their appeal at this time.      

For appeals that need additional action by the school employee, we will mail them a letter describing the next steps in the appeal process. The appeal timelines in WAC 182-32 apply once this letter is mailed.

Dependent verification appeals status update

Many employees included documents with their appeals that met the requirements to verify the requested dependents’ eligibility. In these instances, no further action is needed by the employee. Those employees will soon receive a letter confirming their dependents’ enrollment with coverage effective back to January 1, 2020.

In all other instances of an appeal involving a denied dependent, employees will receive a letter with information about the next step in the appeals process.

DeltaCare appeals status update

All plan change request appeals related to the letter Delta Dental sent to employees in mid-December will be approved. HCA and Delta Dental will honor the request to switch from DeltaCare to Uniform Dental Plan. Affected employees will soon receive a letter confirming the approval with coverage effective back to January 1, 2020.

HCA staff will handle all the keying for these approved dental changes. No action is needed by the benefit administrators regarding these changes