In general, outpatient care received outside of the Yale Health network of health care clinicians and facilities is not covered under Yale Health. The two exceptions to this are outpatient care received for an emergency or urgent condition (see the section Emergency Care Coverage in the Member Coverage Booklet for a full explanation) and care that has been arranged by a Yale Health clinician and approved in advance by the Care Coordination Department.
Frequently Asked Questions
What is out of network coverage?
How will my claim from an outside pharmacy be reimbursed?
You are responsible for the greater of 20% of the cost or the co-pay.
Cost of drug purchased at outside pharmacy: $120
Co-pay (found on the Yale Health Drug List link): $20
20% of your cost of $120: $24
You are responsible for $24 (when purchased at an outside pharmacy). If you had the prescription filled at the Yale Health Pharmacy you would only need to pay $20.
Why might my prescription claim be denied?
When you use an outside pharmacy (not the Yale Health Pharmacy at 55 Lock Street) you will be treated as a cash customer and they will not check to see if your prescription is covered under your insurance plan. This means that when you submit your claim it could be denied because:
- The drug is not covered under the benefit (check the Drug List)
- The drug may require prior authorization (labeled "Prior authorization" on the Drug List)
- The Yale Health co-pay is greater than the amount you paid for the drug (your cost for the drug is $28, but it is a Tier 3 drug, so the co-pay is $35)
- It is too early to fill the prescription
- There is no “days supply” listed on the receipt (see instructions on claim form)
I filed a claim but have not received either reimbursement or notification for several weeks. Is this normal?
If you have not received a response to a claim within 60 days of filing, contact the Yale Health Claims Department at 203-432-0250. Or you can call sooner to see if the claim has been received and is being processed.
I have Yale Health Hospitalization/Specialty Coverage. I received a referral from a Yale Health clinician and obtained prior authorization to see a specialist outside 55 Lock Street. Why did I get a bill from the specialist?
Different network providers have different policies. Some will bill Yale Health directly for prior-authorized services, while some will bill you. Bring or send the bill to the Claims Department and, if the service is covered, the claim will be paid.
What do I do if I’m having a problem getting a claim paid?
Contact the Claims Department at 203-432-0250. A claims representative can answer questions regarding claims processing and Yale Health benefits. The office is open weekdays from 8:30 am to 5 pm. You do not need an appointment.
Is there an appeals process if my claim has been denied, or if I’ve been told by the Claims Department that the service I’ve been referred for won’t be covered?
I have Yale Health Hospitalization/Specialty Coverage. When I saw my primary care clinician we discussed a treatment that might be helpful. I obtained the treatment, paid the bill, and submitted it to Yale Health, but the claim was denied. Why?
Although your clinician may have discussed a treatment, you must receive a referral and have prior approval in order for the treatment to be covered. If you obtain treatment without a referral and prior approval, the claim will not be paid. The same applies if you want a second opinion.