Tier 2 Formal Appeal Request Form

You must have completed and received a determination on your tier 1 telephone review prior to requesting a tier 2 formal appeal.  If you have not completed a tier 1 telephone review, your request for a tier 2 formal appeal will be automatically denied, and if the timeframe has passed for you to request a tier 1 telephone review, your administrative and appeal rights under SHBP are considered exhausted with no right to further appeals.
 
For tier 2 formal appeals, you must submit all relevant information supporting your request for a tier 2 formal appeal determination. Failure to submit relevant information may result in denial of your tier 2 formal appeal
 
Timely appeal: Failure to file your appeal (tier 1 telephone review and/or tier 2 formal appeal, as applicable) within the time allowed, bars any further appeal and your administrative and appeals rights are considered exhausted. This means SHBP automatically denies your appeal.
 
  1. Request for Tier 1 Telephone Review (mandatory): first step of the appeals process. 
  • Request for Tier 1 Telephone Review must occur within 30 days of adverse action (e.g., if retiree disputes October 1 rate increase due to failure to provide Medicare Part B information, Tier 1 Telephone Review must be filed no later than October 31). 
  • Call SHBP Member Services @ 1-800-610-1863 to request Tier 1 Telephone Review. You should receive a determination immediately, unless verification is required. 

     2.  Request for Tier 2 Formal Appeal: final step of the appeals process.

  • Must be submitted within thirty (30) days of the Tier 1 Telephone Review Determination. 
  • Complete form below to submit a Tier 2 Formal Appeal.
After Submitting Tier 2 Formal Appeal:
 
  • You will receive an automated acknowledgement email.
  • You must continue to make premium payments as billed or your coverage will be cancelled. Special note for retirees: When your SHBP coverage is terminated, it CANNOT be reinstated unless you return to work in a benefits eligible position that offers SHBP coverage. Therefore, you will no longer be eligible for coverage with the SHBP.
  • You must continue to comply with all SHBP Eligibility and Enrollment Provisions.
Response Time: Within 90 days of submitting your tier 2 formal appeal, you will receive a tier II formal appeal determination on whether your appeal is approved or denied and your administrative and appeal rights under the SHBP are considered exhausted with no right to further appeals.