Pre-Service Appeal Process for Yale Health Members

You have the right to appeal an adverse benefit determination rendered by Yale Health. The appeal process applies to any adverse benefit determination, which is considered a pre-service claim determination, 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 60 days from the date of receipt of the initial determination. Written first level claim appeal review requests should be mailed to:

Yale Health
Medical Director
P.O. Box 208237
New Haven, CT 06520-8237

Your request should 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 to assist in the review.

Once your appeal has been received, it will be reviewed in detail and the review completed within 15 days of receipt of the appeal, unless the appeal meets the definition of urgent, in which case the review will be completed within 72 hours. The written determination will be issued within 1 business day from the date the appeal decision was made.

Second Level Claim 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. Written second level benefit appeal review requests should be mailed to:

Yale Health
Patient Representative
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. The Yale Health Claims Review Committee will be convened as the second level claim appeal. This meeting shall occur no later than 30 days of receipt of the request, within 72 hours if the determination is urgent. The written determination will be issued within 1 business day from the date the appeal decision was made.

**Third Level Claim Appeal

If the first and second level benefit appeal process maintains the denial, you have the right to request an external Independent Physician Review. Yale Health has contracted with Alicare Medical Management for the provision of this independent review. A request for this level of appeal should be made in writing within 4 months of the second level benefit appeal determination to the Patient Representative at the address noted above. The Patient Representative will assist you in the process of the appeal.

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

**Please note that third level claim appeal is reserved for claims involving “medical judgment”, broadly defined as medical necessity, level of care, health care setting, etc. This does not apply to denials for coverage or benefit exclusions.