Pre-Service Appeal Process

For appeals related to services not yet rendered, you have the right to appeal an adverse benefit determination by Yale Health. The appeal process applies to any adverse benefit determination, which is considered a pre-service appeal, under Yale Health.

First Level Pre-Service Appeal

If a benefit determination is not satisfactory, this is considered an adverse benefit determination, and a first-level 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.

An urgent appeal process is available when the member’s medical condition or treatment requested is deemed clinically urgent or emergent. Urgent Pre-Service Appeals will be reviewed within three (3) calendar days (72 hours) after receipt of the appeal request.  For appeals related to services not yet rendered where an urgent appeal is not required or services do not meet the definition of urgent or emergent, Yale Health will provide a written decision within fifteen (15) calendar days after the receipt of the appeal request.  

First level claim appeal review requests can be emailed to yhappeals@yale.edu or mailed to:

Yale Health Chief Medical Officer
Attn: Appeals
P.O. Box 208282
New Haven, CT 06520-8237

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 208282
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).