Request help with prior authorization or referral requirements

Best first step: Contact your insurance plan or review your plan documents to confirm whether prior authorization or a referral is required before your visit, test, medication, or service.

• Prior authorization is insurance approval requested before some services, tests, medications, or treatments.
• A referral is usually a request or order from one provider for you to see another provider or service.
• Your insurance plan decides whether authorization or referral is required.
• Silent Hill Health may be able to submit clinical information or help confirm the status of a request.
• Approval is not guaranteed, and authorization does not always mean the full cost is covered.
• If care is urgent or an emergency, do not delay care while waiting for authorization guidance.

Requirement	What it usually means
Prior authorization	Your insurance plan reviews a service, medication, test, or treatment before care to decide whether it meets plan requirements for coverage.
Referral	A provider directs you to another provider, specialist, department, test, or service. Some insurance plans require the referral before covering the visit.
Order	A provider requests a test, medication, imaging study, procedure, or service. An order may still need insurance authorization before scheduling or coverage.

• Specialist visits or out-of-network care.
• Imaging such as MRI, CT, ultrasound, or other diagnostic testing.
• Procedures, surgeries, inpatient stays, or observation services.
• Brookhaven behavioral health admission, intensive services, or continuing stay review.
• Certain medications, medication changes, or higher-cost prescriptions.
• Therapy, behavioral health, rehabilitation, or recurring services.
• Durable medical equipment, supplies, or home care services.
• Care that requires proof of medical necessity before coverage.

• Confirm whether a provider order or referral is on file.
• Send clinical information requested by insurance.
• Submit prior authorization requests when Silent Hill Health is responsible for submission.
• Provide visit notes, diagnosis information, test results, or treatment history when appropriate.
• Check whether an authorization request was submitted or is still pending.
• Help correct missing information if insurance asks for more documentation.
• Explain whether an appointment may need to be delayed until review is complete.

Important: Prior authorization approval does not always mean the full cost is covered. Deductibles, copays, coinsurance, network status, benefit limits, and claim rules may still apply.

• Whether prior authorization is required.
• Whether a referral is required.
• Whether the service is covered under your plan.
• Whether the provider or facility is in network.
• Whether medical necessity requirements are met.
• Whether you owe a deductible, copay, or coinsurance.
• Whether a claim is approved, denied, delayed, or partially paid.

• Confirm the insurance plan currently on file is correct.
• Confirm the service, test, medication, appointment, or procedure needing review.
• Confirm the date of the upcoming appointment or service, if scheduled.
• Ask your insurance plan whether prior authorization or referral is required.
• Ask whether the service must be in network.
• Ask whether a specific form, diagnosis, note, or provider order is needed.
• Ask whether authorization must be approved before scheduling or before the date of service.

1. Confirm the service or medication that may require prior authorization or referral.
2. Confirm your current insurance information.
3. Provide the appointment date, service date, or pharmacy request date if known.
4. Share any message from your insurance plan about requirements.
5. Ask whether Silent Hill Health has already submitted the request.
6. Ask what information is still needed.
7. Ask whether the appointment, test, or medication should be delayed until approval is received.
8. Ask who will contact you when the request is approved, denied, delayed, or needs more information.

• Patient full name and date of birth.
• Insurance plan name and member ID, if available.
• Service, test, medication, appointment, or procedure needing review.
• Ordering provider or referring provider, if known.
• Scheduled appointment or service date, if known.
• Facility or department, such as Alchemilla, Brookhaven, imaging, lab, pharmacy, or outpatient care.
• Insurance message, denial letter, authorization number, referral number, or reference number, if available.
• Deadline or urgency, if the appointment or medication will be affected.

• Insurance may need time to review clinical information.
• The insurance plan may request more information before deciding.
• An appointment may need to be rescheduled if approval is not received in time.
• A medication may be delayed if the pharmacy cannot fill it before approval.
• Authorization may be valid only for certain dates, services, facilities, or providers.
• Approval may need to be updated if the service changes.
• Ask whether it is safe to wait if the service is time-sensitive.

Important: A denial from insurance does not always mean the care is not needed. It means the insurance plan did not approve coverage under its rules at that time.

• Ask insurance for the denial reason in writing.
• Ask whether more clinical information is needed.
• Ask whether a peer review, reconsideration, or appeal is available.
• Ask whether a different provider, facility, medication, test, or service is covered.
• Ask Silent Hill Health whether additional documentation can be submitted.
• Ask whether the appointment or treatment plan should change while review continues.
• Ask about self-pay estimates, payment plans, or financial assistance if coverage is not available.

Do not delay emergency care while waiting for prior authorization, referral guidance, insurance approval, or claim review.

• If symptoms are severe or life-threatening, seek emergency care immediately.
• If someone may harm themselves or someone else, use crisis or emergency support.
• If there is a suspected overdose, severe medication reaction, or serious withdrawal concern, use urgent or emergency care.
• If a medication delay may create harm, contact the prescribing team, pharmacy, or urgent care team for guidance.
• If a scheduled service cannot safely wait, ask the care team what options are available while insurance review continues.

Billing and insurance review are separate from emergency care. If you need immediate medical or behavioral health help, do not wait for an insurance response.