Comprehensive Wellness Initiative Policy-- Appeals Process

As set forth in Section VI, subscribers may only appeal their pending benefit plan enrollment change and the additional consequences outlined In Section VI related to tobacco use status testing and administrative errors or other actions for which a member may not be at fault.
Members will remain in the 80/20 Standard Plan during the appeals process.
The Plan will notify the subscriber in writing of the pending benefit plan enrollment change and additional consequences, their appeal rights and information on how to appeal after it is determined that a member has failed the tobacco use status validation testing or failed to submit the completed Physician Certification Form(s) within the deadline.
Member appeals must be filed within fifteen (15) business days of the date of the notification of the pending benefit plan enrollment change and additional consequences. Members shall complete an appeal form and attach a copy of any supporting documents.
If a member’s appeal is unsuccessful, the member’s benefit plan enrollment change and additional consequences will be retroactive to the first day of the month following the testing date. If a member’s appeal is successful, the member will remain in the 80/20 Standard Plan for the benefit year.
Members must exhaust one level of internal administrative review by the Plan or its designee prior to filing a petition for a contested case hearing at the Office of Administrative Hearings.