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Claims

Telephone: 203-432-0250 - Claims Department (press 2)
Fax: 203-432-8254
Hours: Monday through Friday, 8:30 am - 5:00 pm
Location: 55 Lock Street, 3rd Floor, Business Office

Our services | Our staff | FAQs

Our Services

Representatives are available to answer questions regarding claims processing and Yale Health benefits. You do not need an appointment to come in and talk with a representative.

Claims for medical services should be accompanied by itemized bills (charge card receipts and balance due statements are not acceptable). Bills must include provider name and address as well as diagnosis and procedure codes for determination of coverage. Claims forms can be brought to the Business Office at 55 Lock Street on tth 3rd floor.

Claim forms are available in the Claims Department or can be downloaded here.

Please submit claims to:

Yale Health
Claims Department
P.O. Box 208217
New Haven, CT 06520-8217

Prescription claims must be accompanied by a prescription receipt containing the patient name, physician name, prescription number, prescription date, prescription charge, National Drug Code, and pharmacy name and address. Prescription claim forms can be downloaded here and should be mailed to the address on the form.

Claims are honored for one year from the date of service. If the delay is the responsibility of the clinician or facility who rendered the service, the deadline may be extended. If you haven't received a response to a claim within 60 days of filing, contact the Claims Department. You may call sooner to inquire if the claim has been received and is in process.

Our Staff

Manager:	Connie Rollinson
Accountant Assistant:	Marybeth Massaro

FAQs

Do I have health care coverage when I am out of state?
You are covered for emergency care, Acute Care, and pre-authorized short-term follow-up care. Please see the Out of Network Coverage section in the Member Coverage Booklet for details.

What is considered an emergency?
An emergency condition is defined as a major acute medical problem or major acute trauma that requires immediate medical attention, or a condition that could lead to serious harm if treatment is not received or is delayed.

What should I do if I have an emergency?
First and foremost, you should seek care.Your health and well being are of greatest importance! You do not need to call Yale Health before receiving emergency treatment. However, you should notify the Care Coordination Department (203-432-7397) within 2 business days of receiving treatment so that we may coordinate insurance coverage with the provider from whom you received the emergency care.

What if I am away and have a serious problem that might not qualify as an emergency?
You are also covered outside of CT for urgent situations. An urgent medical situation is the sudden and unexpected onset of an acute medical problem or trauma requiring immediate medical attention. Care for non-acute phases of chronic conditions, maintenance care, and routine care are not considered urgent. If you are able to, you can call Acute Care (203-432-0123 or 877-947-2273) or your clinician to obtain medical advice over the phone. If that is not possible or appropriate, you should seek the care you need. If you are out-of-state, you may receive Acute Care at any medical facility and receive the same coverage as for emergency care, including short-term follow-up care if pre-authorized.

What happens if circumstances prevent me from contacting Yale Health within 48 hours?
If your condition prevents you or your representative from contacting the Care Coordination Department within 48 hours, you will still be covered for the emergency but you should contact Care Coordination as soon as possible to ensure that Yale Health clinical staff are aware of your condition and to request Care Coordination to authorize follow-up care if it is needed. Remember to carry your Yale Health card with you at all times; it can provide valuable information if you can’t communicate.

What if my emergency requires follow-up care?
Short-term follow-up care that is pre-authorized will be covered. Yale Health clinical staff will assist in coordinating follow-up care. For assistance with preauthorization, call Yale Health ’s toll-free number: 877-947-2273.

What should I do for follow-up care if I leave New Haven and need to continue treatment begun here?
Each person requires a different treatment plan, so you should consult with your clinician. In general, if you are on a treatment plan and are going to travel, your clinician will be able to develop a method of ensuring care as you travel. Please
remember that while emergency and Acute Care are covered while you are out of the area, routine care is not covered by Yale Health.

How do I obtain prescription refills while I am away?
Have your clinician call in a refill order to a local pharmacy and have it refilled there. Retain the receipt and submit it to the Claims Department for reimbursement with the appropriate form (Forms & Brochures).

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 (PA on  the Drug List)
• it is too early to fill the prescription (see chart)
• 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 $30)
• there is no “days supply” listed on the receipt (see instructions on claim form)

Your pharmacy benefit is subject to the rules and limitations of the formulary (Member Coverage Booklet) even when you use an outside (out-of-network) pharmacy.

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. 

Example:
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.

I was referred by a Yale Health clinician for a medical procedure within the Yale Health network but outside Yale Health Center, 55 Lock Street, a procedure I thought was covered. Why did I receive a bill?
Check to make sure that what you received is actually a bill. It may be a copy of the invoice describing the procedure and telling you that the claim has been sent to Yale Health for payment. If it is a bill there may have been an error. Contact the Yale Health Claims Department (203-432-0250).

How do I file a claim with Yale Health?
Claims for reimbursement of covered services should be accompanied by itemized bills for services rendered (charge card receipts and balance due statements are not acceptable). Bills for services must include diagnosis, provider name,
credentials, address, telephone number, tax ID number and procedure codes for determination of coverage. Claim forms are available in the Claims Department or can be downloaded from our Forms & Brochures page. Please submit claims to Yale Health Claims Department / Yale Health / P.O. Box 208217 / New Haven, CT 06520-8217 or drop off at the Yale Health Center, Business Office, 55 Lock Street, 3rd floor.

How long do I have to file a claim?
Claims for covered services are honored for one year from the date of service. If the delay is caused by the clinician or facility who rendered the service or is related to the coordination of benefits process, the deadline may be extended.

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 (203-432-0250). Or you can call sooner to see if the claim has been received and is being processed.

My Yale Health clinician and I discussed a treatment that might be helpful. I obtained the treatment, paid the bill, and submitted the claim 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 from the Yale Health Care Coordination Department 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 policy applies if you want a second opinion.

I received a referral from a Yale Health clinician and obtained prior authorization to see a specialist outside Yale Health Center. But I just got billed by the specialist. Why?
Different network providers have different policies; some will bill Yale Health directly for prior-approved 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 am having a problem getting a claim paid?
Contact the Claims Department (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 5:00 pm.

Is there an appeals process if my claim has been denied or if I have been told by the Claims Department that the service for which I’ve been referred will not be covered?
If your claim is denied you have a right to appeal the decision. The appeals process involves two levels.The first level appeal requires a request for reconsideration in writing within 180 days from the date of receipt of the initial determination. First level requests must be mailed to the Yale Health, Manager,
Claims Department.

The first review will be completed within 30 days of receipt of the appeal.You will be contacted if further information is needed to assist in the determination. The written determination will be issued within 5 business days from the date the appeal decision is made.

If you do not agree with the first level claim appeal decision, a second level claim appeal may be requested. Second level appeals must be requested in writing within 60 days of receipt of the first level claim appeal determination and mailed to the Yale Health Patient Representative. The Yale Health Claims Review Committee will be convened to consider the second level claim appeal. The second review will be completed within 30 days of receipt of the appeal. The decision of the Claims Review Committee will be issued within 5 business
days from the date the appeal decision was made.

For further information on your appeal rights, please contact the Yale Health, Manager, Claims Department (203-432-1003) who will guide you through the appeals process.

Once you have exhausted the above appeals, should the initial claim determination be upheld, you have a right to bring a civil action under Section 502(a) of the Employee Retirement Income Security Act of 1974 (ERISA).

What is out of network coverage?
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.

What is emergency care?
Emergency care and preauthorized follow-up care are covered at 100% regardless of location. An emergency condition is defined as a major acute medical problem or major acute trauma that requires immediate medical attention or a condition that could lead to serious harm or death if care is not received or is delayed. Coverage includes emergency facility fees, laboratory expenses, radiological expenses, emergency physicians’ fees, ambulance transportation, and pre-authorized short-term follow-up care. If you need emergency care, go to the nearest emergency facility for treatment. Treatment for emergency conditions is covered at emergency facilities worldwide. Please see the Out of Network Coverage section in the Member Coverage Booklet.

Please contact the Yale Health Care Coordination Department (203-432-7397), Acute Care (203-432-0123) or if out of the Yale Health service area, call our toll-free number (1-877-947-2273) within two business days of receiving emergency outpatient treatment or being admitted to an emergency facility. The Care Coordination Department will (1) notify Yale Health clinical staff of your condition so that they can coordinate your care as appropriate or make further arrangements for your care and (2) pre-authorize any necessary followup care.Follow-up care that is not pre-authorized may be denied. If Yale Health deems it appropriate,Yale Health may arrange for and cover the expenses of transporting you to a Yale Health-approved facility to receive follow-up care. If the severity of your medical condition prevents you or your representative from contacting the Yale Health Care Coordination Department within 48 hours, you will still be covered for the emergency but you should contact Care Coordination as soon as possible.You are strongly encouraged to carry your Yale Health membership card with you at all times to ensure that someone will be able to contact Yale Health in the event of an incapacitating emergency.

What is Acute Care?
Acute Care is covered at 100% when it is received at the Acute Care Department (203-432-0123) at Yale Health.An urgent condition is defined as the sudden and unexpected onset of an acute medical problem or trauma that requires immediate medical attention. Care for non-acute phases of chronic conditions, maintenance care and routine care are not considered urgent. If you are out-of-state you are considered out of area and you may receive Acute Care at any medical facility and receive the same coverage
as for emergency care, including pre-authorized short-term follow-up care.Please see the Out of Network Coverage section in the Member Handbook for details.

In other words, no distinction is made in coverage between Acute Care and emergency care received out of area; the distinction between Acute Care and emergency care applies
only when you are within New Haven County. For out-of-area Acute Care, you should contact the Yale Health Care Coordination Department (877-947-2273) within 48 hours (or two business days) to ensure that Yale Health clinical staff are aware of your condition and if necessary, to request the Care Coordination Department to pre-authorize follow-up care. Follow-up care that is not pre-authorized may be denied.

If, in the judgment of Yale Health, the illness or injury does not meet the plan definition of an emergency or urgent condition, coverage will be denied. This includes all elective admissions or treatments. Coverage will also be denied for conditions that could have been treated at Yale Health while the member or enrolled dependent was in area.

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