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. Although technical support staff may assist the clinicians in data gathering, technical staff members are not permitted to make clinical judgments. Kelsey-Seybold Utilization Management staff relies on publishing 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.