How to Appeal an Administrative Decision
Eligibility/Enrollment
If an enrollment or eligibility request submitted to the Trust Office is denied in whole or in part, the Trust Office will provide you with a notice identifying the reason(s) for the denial, any other information needed to consider your request and your right to obtain additional information about the Trust's eligibility and enrollment rules. You may appeal an adverse eligibility or enrollment decision by filing a written appeal with the Trust Office within 180 days of the denial. Appeals should be sent to the following address:
School District No. 1 Health and Welfare Trust Appeals
P.O. Box 12267
Seattle, WA 98102
The appeal shall identify the eligibility or enrollment determination involved, set forth the reasons for the appeal and provide any additional information you believe is relevant. Your appeal will not be considered and the denial by the Trust Office will be final if no appeal is received within 180 days.
Appeals Procedures for the Trust Vision Plan
Appeal of Denied Claims: Under the Plan, if a claim is denied in whole or in part, you or your authorized representative may request a full review of the denial. You may designate any person, including your provider, as your authorized representative.
Initial Appeal: The request must be made within 180 days following denial of a claim and should contain sufficient information to identify the Trust participant for whom the claim was denied, including the VSP enrollee's name, the VSP enrollee's member identification number, the Trust participant's name and date of birth, the provider's name, and the claim number. You may review during normal working hours any documents held by VSP pertinent to the denial. You may also submit written comments or supporting documentation concerning the claim to assist in VSP's review. VSP's response to the initial appeal, including specific reasons for the decision, will be provided and communicated to you as follows:
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Prior authorization for visually necessary or appropriate services: within 30 calendar days after receipt of your request for an appeal; and
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Denied claims for services rendered: within 30 calendar days after receipt of your or your authorized representative's request for an appeal.
Second Level Appeal: If you or your authorized representative disagrees with the response to the initial appeal of the claim, you or your authorized representative has the right to a second level appeal. Within 60 days after receipt of VSP's response to the initial appeal, you or your authorized representative may submit a second appeal to VSP along with any pertinent documentation. VSP will communicate its final determination to you or your authorized representative in compliance with applicable state and federal laws and regulations and will include the specific reasons for the determination.
Other Remedies: If you remain dissatisfied after completing the VSP appeals process, you may request that the Trust review your appeal. Details about how to access the Trust Claim Appeal Procedures are set forth below.
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