Claims and Referrals

Telephone:

• 203-432-0250 - Claims Department (press 2)
• 203-432-7397 - Outpatient referrals

Hours: Monday through Friday, 8:30 am - 5:00 pm
Location: 55 Whitney Ave, 2nd Floor, Business Office

Representatives are available to answer questions regarding claims processing and YHP 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. The claims drop off box is located in the first floor lobby at 17 Hillhouse Avenue.

Prescription claims must contain the patient name, physician name, prescription number, prescription date, prescription charge, National Drug Code, and pharmacy name and address.

Claim forms are available in the Claims Department or can be downloaded from the YUHS web site at www.yale.edu/uhs. Please submit claims to Yale Health Plan / Claims Department/ P.O. Box 208217 / New Haven, CT 06520-8217. Claims can also be placed in the Claims Drop boxes at YUHS, 17 Hillhouse Avenue.

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.

Outpatient referrals

If you are referred for care outside of the 17 Hillhouse Avenue building, an Outpatient Referral form is generated by your clinician or another authorized person in that department.

Process

• The referral may be generated and approved within the department and a copy of the approved referral given to you at the time.
• The referral may be pended for review by the Care Coordination Department. If the claim is pended, the referral is reviewed and you will receive a copy of the approved referral (if time permits) or the approval will be faxed to the appropriate service site and you will receive a call that the referral is approved.

If you have alternate (non-YHP) hospitalization and specialty coverage, make sure to take your insurance card and any other pertinent information to the outside provider so that your other insurance can be billed. Make sure that the person who checks you in for your appointment records all the information correctly.

A referral covers only the specific services requested on the form by your YHP clinician upon approval by the YHP Care Coordination Department. If the outside clinician feels you need additional consultations, treatments, or testing, that clinician must contact the referring YHP clinician to have a new referral generated for additional services. Make sure to check with your clinician or the Care Coordination Department (432-7397) to assure that another referral has been initiated and approved before additional services are rendered.