All the information you need for a 2017 Well-Being Incentive Credits appeal.

Members and covered spouse who wish to appeal a 2017 well-being incentive credits distribution for well-being activities completed in 2017, please use the forms below for instruction and submission.

DEADLINE

Appeals, along with the requested documents, must be submitted by 5:00 pm, ET January 31, 2018.  Well-Being Incentive Credits Appeals submitted after this date will be denied.

LEVEL 1 – WELL-BEING INCENTIVE CREDITS APPEALS

To file a Well-Being Incentive Credits Appeal, complete all applicable sections on the Level 1 – 2017 Well-Being Incentive Credits Appeal form, sign and date the form and submit according to the instructions on the form.

If the 2017 Incentive Action in question was not satisfied due to circumstances beyond your control, you should explain why in the space provided on the 2017 Well-Being Incentive Credits Appeal Form. Examples of “circumstances beyond your control” include, but are not limited to, the following: long-term hospital stay, and hospice stay.

You should submit the form, along with the supporting documentation. An example of appropriate supporting documentation includes:

  • A copy of the completed 2017 Physician Screening Form (if applicable).
  • A copy of completed screening consent form containing results as proof of onsite screening participation upon completion at a SHBP sponsored event
  • When the online Well-Being Assessment through BeWellSHBP.com is complete, print a copy of the report.
  • When activities through the coaching or online pathway are complete, print screen the rewards balance page.

Click here to download the Level 1 2017 Well-Being Incentive Credits Appeal form.
Instructions are included on the form.

Level 1 well-being incentive credits appeal form

LEVEL 2 – FORMAL APPEAL

If your Level 1 – 2017 Well-Being Incentive Credits Appeal is denied, you may file a Formal Appeal, which must be postmarked within 15 calendar days following the date of the 2017 Level 1 – Well-Being Incentive Credits Appeal decision. To file a Formal Appeal, you must complete the Level 2- 2017 Well-Being Incentive Credits Appeal Form and attach a copy of the 2017 Level 1- Appeal decision, along with any supporting documentation. 

Click here to download the Level 2 2017 Well-Being Incentive Credits Appeal form.
Instructions are included on the form.

Generally, a decision by the Formal Appeal committee will be issued within 30 thirty (30) calendar days following receipt. The written notice of the decision by the Committee is the final step in the administrative proceedings and will exhaust all administrative remedies.

Level 2 well-being incentive credits appeal form