Post-Service Appeal Process
For services already rendered, you have the right to appeal an adverse claim determination by Yale Health. The appeal process applies to any adverse claim determination, which is considered a post-service appeal, under Yale Health.
First Level Claim Appeal
If a benefit determination is not satisfactory, this is considered an adverse benefit determination, and a first-level claim appeal review of the adverse determination may be requested. The first level appeal may be requested in writing within 6 (six) months (180 days) from the date of receipt of the initial determination. First-level claim appeal review requests can be emailed to yhappeals@yale.edu or mailed to:
Yale Health
Appeals Department
P.O. Box 208282
New Haven, CT 06520-8237
Your written and signed request must include the name and Yale Health identification number of the member requesting the review, names of health care providers or staff involved, relevant dates, and any supporting documentation (e.g., provider notes, photographs, Letters of Medical Necessity, clinical studies, or test results) to assist in the review.
Yale Health will provide a written decision within thirty (30) calendar days after the receipt of the appeal request.
Second Level Appeal
If the first-level benefit appeal decision is not satisfactory, a second-level benefit appeal may be requested. The second-level benefit appeal may be requested in writing within 60 days of receipt of the first-level benefit appeal determination. Second level benefit appeal review requests should be emailed to yhappeals@yale.edu or mailed to:
Yale Health
Appeals Department
P.O. Box 208237
New Haven, CT 06520-8237
Your request should include steps previously taken, any additional documentation supporting the second-level benefit appeal and the reasons for further appeal. Yale Health will review the complete appeal and will provide a written decision within forty-five (45) days after the receipt of the appeal request. A written determination will be mailed to the member within 1 business day from the date the appeal decision was made.
If all appeal levels have been exhausted and the determination is upheld, you may have the right to bring a civil action under Section 502(a) of the Employee Retirement Income Security Act of 1974 (ERISA).