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Claims

Telephone: 203-432-0250 - Claims Department (press 2)
Hours: Monday through Friday, 8:30 am - 5:00 pm
Location: 55 Whitney Ave, 2nd Floor, Business Office

Our services | Our staff | FAQs

Our Services

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.

Claim forms are available in the Claims Department or can be downloaded here.

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.

Prescription claims must be accompanied by a prescription receipt containing the patient name, physician name, prescription number, prescription date, prescription charge, National Drug Code, and pharmacy name and address. Prescription claim forms can be downloaded here and should be mailed to the address on the form.

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.

Our Staff

Manager:	Connie Rollinson
Claims Coordinator:	Denise Allen
Accountant Assistant:	Marybeth Massaro

FAQs

Do I have health care coverage when I am out of state?
You are covered for emergency care, urgent care, and pre-authorized short-term follow-up care. Please see the Out of Network Coverage section in the Member Handbook for details (YPBA go to this handbook).

What is considered an emergency?
An emergency condition is defined as a major acute medical problem or major acute trauma that requires immediate medical attention, or a condition that could lead to serious harm if treatment is not received or is delayed.

What should I do if I have an emergency?
First and foremost, you should seek care.Your health and well being are of greatest importance! You do not need to call YHP before receiving emergency treatment. However, you should notify the Care Coordination Department (203-432-7397) within 2 business days of receiving treatment so that we may coordinate insurance coverage with the provider from whom you received the emergency care.

What if I am away and have a serious problem that might not qualify as an emergency?
You are also covered outside of CT for urgent situations. An urgent medical situation is the sudden and unexpected onset of an acute medical problem or trauma requiring immediate medical attention. Care for non-acute phases of chronic conditions, maintenance care, and routine care are not considered urgent. If you are able to, you can call Urgent Care (203-432-0123 or 877-YHP-CARE) or your clinician to obtain medical advice over the phone. If that is not possible or appropriate, you should seek the care you need. If you are out-of-state, you may receive urgent care at any medical facility and receive the same coverage as for emergency care, including short-term follow-up care if pre-authorized.

What happens if circumstances prevent me from contacting YHP within 48 hours?
If your condition prevents you or your representative from contacting the Care Coordination Department within 48 hours, you will still be covered for the emergency but you should contact Care Coordination as soon as possible to ensure that YHP clinical staff are aware of your condition and to request Care Coordination to authorize follow-up care if it is needed. Remember to carry your YHP card with you at all times; it can provide valuable information if you can’t communicate.

What if my emergency requires follow-up care?
Short-term follow-up care that is pre-authorized will be covered. YHP clinical staff will assist in coordinating follow-up care. For assistance with preauthorization, call YHP’s toll-free number: 877-YHP-CARE (877-947-2273).

What should I do for follow-up care if I leave New Haven and need to continue treatment begun here?
Each person requires a different treatment plan, so you should consult with your clinician. In general, if you are on a treatment plan and are going to travel, your clinician will be able to develop a method of ensuring care as you travel. Please
remember that while emergency and urgent care are covered while you are out of the area, routine care is not covered by YHP.

How do I obtain prescription refills while I am away?
Have your clinician call in a refill order to a local pharmacy and have it refilled there. Retain the receipt and submit it to the Claims Department for reimbursement with the appropriate form (Forms & Brochures).

I was referred by a YHP clinician for a medical procedure within the YHP network but outside 17 Hillhouse Avenue, a procedure I thought was covered. Why did I receive a bill?
Check to make sure that what you received is actually a bill. It may be a copy of the invoice describing the procedure and telling you that the claim has been sent to YHP for payment. If it is a bill there may have been an error. Contact the YHP Claims Department (203-432-0250).

How do I file a claim with YHP?
Claims for reimbursement of covered services should be accompanied by itemized bills for services rendered (charge card receipts and balance due statements are not acceptable). Bills for services must include diagnosis, provider name,
credentials, address, telephone number, tax ID number and procedure codes for determination of coverage. Claim forms are available in the Claims Department or can be downloaded from our Forms & Brochures page. Please submit claims to YHP Claims Department / Yale Health Plan / 55 Whitney Avenue /
P.O. Box 208217 / New Haven, CT 06520-8217 or place in claims drop boxes at YUHS, 17 Hillhouse Avenue.

How long do I have to file a claim?
Claims for covered services are honored for one year from the date of service. If the delay is caused by the clinician or facility who rendered the service or is related to the coordination of benefits process, the deadline may be extended.

I filed a claim but have not received either reimbursement or notification for several weeks. Is this normal?
If you have not received a response to a claim within 60 days of filing, contact the YHP Claims Department (203-432-0250). Or you can call sooner to see if the claim has been received and is being processed.

My YHP clinician and I discussed a treatment that might be helpful. I obtained the treatment, paid the bill, and submitted the claim to YHP. But the claim was denied. Why?
Although your clinician may have discussed a treatment, you must receive a referral and have prior approval from the YHP Care Coordination Department in order for the treatment to be covered. If you obtain treatment without a referral and prior approval, the claim will not be paid. The same policy applies if
you want a second opinion.

I received a referral from a YHP clinician and obtained
prior authorization to see a specialist outside 17 Hillhouse Avenue. But I just got billed by the specialist. Why?
Different network providers have different policies; some will bill YHP directly for prior-approved services, while some will bill you. Bring or send the bill to the Claims Department and, if the service is covered, the claim will be paid.

What do I do if I am having a problem getting a claim paid?
Contact the Claims Department (203-432-0250). A claims representative can answer questions regarding claims processing and YHP benefits. The office is open weekdays from 8:30 am to 5:00 pm.

Is there an appeals process if my claim has been denied or if I have been told by the Claims Department that the service for which I’ve been referred will not be covered?
If your claim is denied you have a right to appeal the decision. The appeals process involves two levels.The first level appeal requires a request for reconsideration in writing within 180 days from the date of receipt of the initial determination. First level requests must be mailed to the Yale Health Plan, Manager,
Claims Department.

The first review will be completed within 30 days of receipt of the appeal.You will be contacted if further information is needed to assist in the determination. The written determination will be issued within 5 business days from the date the appeal decision is made.

If you do not agree with the first level claim appeal decision, a second level claim appeal may be requested. Second level appeals must be requested in writing within 60 days of receipt of the first level claim appeal determination and mailed to
the Yale Health Plan Patient Representative. The Yale Health Plan Claims Review Committee will be convened to consider the second level claim appeal. The second review will be completed within 30 days of receipt of the appeal. The decision of the Claims Review Committee will be issued within 5 business
days from the date the appeal decision was made.

For further information on your appeal rights, please contact the Yale Health Plan, Manager, Claims Department (203-432-1003) who will guide you through the appeals process.

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

What is out of network coverage?
In general, outpatient care received outside of the YHP network of health care clinicians and facilities is not covered under YHP.The two exceptions to this are outpatient care received for an emergency or urgent condition (see the section Emergency Care Coverage in the Member Handbook for a full explanation, YPBA go to this handbook) and care that has been arranged by a YHP clinician and approved in advance by the Care Coordination Department.

What is emergency care?
Emergency care and preauthorized follow-up care are covered at 100% regardless of location. An emergency condition is defined as a major acute medical problem or major acute trauma that requires immediate medical attention or a condition that could lead to serious harm or death if care is not received or is delayed. Coverage includes emergency facility fees, laboratory expenses, radiological expenses, emergency physicians’ fees, ambulance transportation, and pre-authorized short-term follow-up care. If you need emergency care, go to the nearest emergency facility for treatment. Treatment for
emergency conditions is covered at emergency facilities worldwide. Please see the Out of Network Coverage section in the Member Handbook for details (YPBA go to this handbook).

Please contact the YHP Care Coordination Department (203-432-7397), Urgent Care (203-432-0123) or if out of the YHP service area, call our toll-free number (1-877-947-2273) within two business days of receiving emergency outpatient treatment or being admitted to an emergency facility. The Care Coordination Department will (1) notify YHP clinical staff of your condition so that they can coordinate your care as appropriate
or make further arrangements for your care and (2) pre-authorize any necessary followup care.Follow-up care that is not pre-authorized may be denied. If YHP deems it appropriate,YHP may arrange for and cover the expenses of transporting you to a YHP-approved facility to receive follow-up care. If the severity of your medical condition prevents you or your representative from contacting the YHP Care Coordination Department within 48 hours, you will still be covered for the emergency but you should contact Care Coordination as soon as possible.You are strongly encouraged to carry your YHP membership card with you at all times to ensure that someone will be able to contact YHP in the event of an incapacitating emergency.

What is urgent care?
Urgent care is covered at 100% when it is received at the Urgent Care Department (203-432-0123) at YUHS.An urgent condition is defined as the sudden and unexpected onset of an acute medical problem or trauma that requires immediate medical attention. Care for non-acute phases of chronic conditions, maintenance care and routine care are not considered urgent. If you are out-of-state you are considered out of area and you may receive urgent care at any medical facility and receive the same coverage
as for emergency care, including pre-authorized short-term follow-up care.Please see the Out of Network Coverage section in the Member Handbook for details (YPBA go to this handbook).

In other words, no distinction is made in coverage between urgent care and emergency care received out of area; the distinction between urgent care and emergency care applies
only when you are within New Haven County. For out-of-area urgent care, you should contact the YHP Care Coordination Department (877-947-2273) within 48 hours (or two business days) to ensure that YHP clinical staff are aware of your condition and if necessary, to request the Care Coordination Department to pre-authorize follow-up care. Follow-up care that is not pre-authorized may be denied.

If, in the judgment of YHP, the illness or injury does not meet the plan definition of an emergency or urgent condition, coverage will be denied. This includes all elective admissions or treatments. Coverage will also be denied for conditions that could have been treated at YUHS while the member or enrolled dependent was in area.