Pre-Service Appeal Process for Yale University Students

You have the right to appeal an adverse benefit determination rendered by Yale Health. The appeal process applies to any adverse benefit determination made under Yale Health, including pre-service claim determinations.

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 of 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 will be 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 appeal for claims. 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.