Flexible Benefits Eligibility and Enrollment Appeals
Eligibility and Enrollment appeals consist of, but are not limited to, the following:
- Qualifying Life Events (QLEs)
- Reinstatement of coverage
- COBRA
- Dependent Verification
To initiate a Flexible Benefits eligibility and enrollment appeal, see the steps below.
First Level – Telephone Review
The Telephone Review is the first step of the appeal process. To request a telephone review, please call the GaBreeze Benefits Center at 877-342-7339 within 30 days of an adverse action. The GaBreeze representative should provide you with a decision regarding your eligibility for Flexible Benefits Plan coverage during this telephone review. If you disagree with the decision rendered, you may request to file an official appeal with the Department of Administrative Services (DOAS)/Human Resources Administrative (HRA) Division. The GaBreeze representative will mail an appeal form to your address on file.
Second Level - Official Appeal
You must complete and return all pages of the appeal form within 45 days from the statement date listed on the form. You should include any supporting documentation. The completed form must be returned to the Plan administrator (DOAS/HRA). Failure to return the completed appeal form by the due date will result in an automatic denial of your appeal. The second level is the final step of the appeal process.
Approval/Denial of the Second Level
You will receive a written second-level appeal determination within 30 days of receipt of your appeal. If additional time is required, you will be notified.
The Department of Administrative Services (DOAS)/Human Resources Administrative (HRA) Division has the final decision on eligibility and enrollment appeals. The appeal decisions may be subject to review and determination by HRA’s Appeals Committee.
If your appeal is approved, coverage will be retroactive to the date the participant and/or dependent was first eligible or the first of the following month of the qualifying life event. The participant must pay any retroactive premiums if applicable.
Note: You must appeal directly to the Flexible Benefits Program’s vendors for adverse actions related to claims. Additionally, the State Health Benefit Plan, administered by the Department of Community Health, has a separate appeal process available on their website.