Utilization Management Policy

The Kelsey-Seybold Utilization Management staff at Kelsey-Seybold Clinic is responsible for verifying that medical services that are requested for authorization by participating physicians meet the medical necessity criteria set forth in the member’s certificate of coverage for treating the member’s illness or injury. Kelsey-Seybold Utilization Management does not reward its associates for issuing denials and does not offer incentives to encourage inappropriate under or over utilization. Kelsey-Seybold Utilization Management uses licensed clinical professionals (including RNs and physicians) in its review of medical information. Kelsey-Seybold Utilization Management staff relies on published criteria and clinical guidelines to make determinations relative to whether the service or treatment meets the medical necessity criteria in the member’s certificate of coverage. Any case that a nurse is unable to certify based on the criteria is referred to a physician. Treating physicians may contact the UM Department at 713-442-5339 to discuss benefit denial.

Members that participate in Medicare Advantage plans have the right to view all criteria standards used to make a determination. Below are the links to Center for Medicare Services National Coverage Determinations and Local Coverage Determinations. In the event that Kelsey-Seybold does not have available National or Local Coverage Determinations, decisions will be made using Interqual™ content. Interqual content is available for both providers and members by accessing the link provided below.

For members enrolled in health plans that delegate utilization management responsibilities to Kelsey-Seybold, medical-necessity determinations are made using the applicable plan’s designated hierarchy of review. Depending on the member’s plan and benefit coverage, this hierarchy may include federal or state coverage requirements, the health plan’s medical and pharmacy policies, nationally recognized clinical guidelines, and other approved criteria. The member’s benefit plan document governs if there is a conflict among these resources. Additional information about the criteria and policies applicable to each delegated health plan is available through the links below: