Understand how insurance claims are processed

Best first step: Keep your insurance information up to date before care, and compare your Silent Hill Health bill with your insurance explanation of benefits after the claim processes.

• Silent Hill Health may send a claim to insurance after care is provided.
• Your insurance plan reviews the claim based on your coverage, benefits, network rules, prior authorization, referral requirements, and plan limits.
• Insurance may pay, deny, delay, partially pay, request more information, or apply the cost to deductible, copay, or coinsurance.
• Your explanation of benefits is from insurance. Your bill is from Silent Hill Health.
• One visit may create more than one claim or bill.
• If a claim is denied, delayed, or does not match your bill, contact billing and your insurance plan for review.

Step	What usually happens
Care is provided	You receive care at Alchemilla, Brookhaven, emergency services, outpatient care, lab, imaging, pharmacy, or another service.
Charges are created	Silent Hill Health records the services, departments, providers, and charges connected to the visit.
Claim is sent to insurance	The claim is submitted using the insurance information on file.
Insurance reviews the claim	Insurance reviews coverage, benefits, network status, medical necessity, prior authorization, referrals, and plan rules.
Insurance processes the claim	Insurance may pay, deny, partially pay, apply deductible, or request more information.
Patient balance is created	Silent Hill Health bills the patient or guarantor for any remaining balance after insurance processing, payments, and adjustments.

• Whether the patient was eligible for coverage on the date of service.
• Whether Silent Hill Health, the provider, or the service was in network.
• Whether the service is covered under the plan.
• Whether prior authorization or a referral was required.
• Whether the service met medical-necessity or plan requirements.
• Whether deductible, copay, coinsurance, or benefit limits apply.
• Whether more information is needed before the claim can be processed.

Status	What it may mean
Submitted	Silent Hill Health has sent the claim to insurance, but insurance has not completed review.
Pending	Insurance is reviewing the claim or waiting for more information.
Paid	Insurance processed payment for all or part of the claim.
Partially paid	Insurance paid some charges but left other amounts as patient responsibility or denied certain services.
Denied	Insurance did not approve payment for all or part of the claim.
Needs more information	Insurance may need records, authorization details, coordination of benefits, or corrected claim information before deciding.

Important: An explanation of benefits may say “this is not a bill.” Your Silent Hill Health bill shows the amount currently requested from the patient or guarantor after insurance activity is applied.

• Amount billed by the provider or facility.
• Amount allowed by the insurance plan.
• Amount paid by insurance.
• Adjustments or discounts applied by insurance.
• Amount applied to deductible, copay, or coinsurance.
• Denied or noncovered amounts, if any.
• Appeal instructions or denial reason, if applicable.

• Deductible amount assigned by insurance.
• Copay or coinsurance amount.
• Noncovered or denied service amount.
• Out-of-network balance, if applicable.
• Charges remaining after insurance payment and adjustments.
• Balances from more than one claim or date of service.
• Corrected balance after insurance reprocesses the claim.

• Insurance information may need to be corrected or updated.
• Insurance may request additional documentation.
• A claim may need prior authorization or referral information.
• Multiple claims may process at different speeds.
• Insurance may coordinate benefits with another insurance plan.
• Claims may be corrected, resubmitted, denied, or reprocessed.
• Statements may be generated before later payments or adjustments post.

• Facility charges may process separately from provider charges.
• Emergency care may process separately from inpatient or follow-up care.
• Lab, imaging, pharmacy, or diagnostic services may process separately.
• Provider interpretation may process separately from the test itself.
• Brookhaven behavioral health services may process separately from Alchemilla medical services.
• Different claims may have different insurance decisions, payment dates, or patient balances.

• Behavioral health benefits may be processed separately from medical benefits.
• Inpatient or observation care may require authorization or continuing stay review.
• Insurance may request clinical documentation before processing payment.
• Level of care may be reviewed by the insurance plan.
• Some sensitive documentation may require special handling before it is shared with insurance.
• A Brookhaven bill may arrive separately from an Alchemilla emergency or medical bill.

• Confirm Silent Hill Health has the correct insurance information.
• Watch for an explanation of benefits from your insurance plan.
• Keep claim numbers, reference numbers, and denial letters.
• Save payment confirmations and receipts.
• Compare your EOB with your Silent Hill Health bill.
• Ask whether a bill is waiting for insurance processing before paying.
• Contact billing if a payment, adjustment, or claim decision does not match your records.

Contact	Ask about
Silent Hill Health billing	Whether the claim was submitted, what insurance is on file, billing corrections, itemized statements, payments, and account balance.
Silent Hill Health care team or scheduling team	Orders, referrals, medical documentation, prior authorization status, and whether care should be delayed.
Your insurance plan	Coverage rules, claim status, denial reasons, appeal deadlines, network status, deductible, copay, coinsurance, and benefit limits.

Do not delay emergency or urgent care because of claim processing, coverage questions, prior authorization, referral requirements, or a denied claim.

• 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 or treatment delay may cause harm, contact the prescribing team, pharmacy, or urgent care team for guidance.
• If you received a final notice, collection notice, or urgent insurance deadline, contact billing and your insurance plan as soon as possible.

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.