Clinical Criteria

KelseyCare Advantage uses Kelsey-Seybold Utilization Management and Optum Behavioral Health to process coverage decisions on your behalf.

Medical (non-behavioral health) Clinical Criteria & Guidelines

Kelsey-Seybold uses National Coverage Determinations and Local Coverage Determination Criteria based on sound clinical evidence to make coverage determinations, as well as to inform discussions about evidence-based practices and discharge planning.

In using its Clinical Criteria, Kelsey-Seybold takes individual circumstances and the local delivery system into account when determining coverage. The following are the Local and National Coverage Determinations used by Kelsey-Seybold to make coverage decisions. Please note other Clinical Criteria may apply outside of or in addition to the following criteria due to superseding federal or state requirements, and/or specific contractual requirements.

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.

Medicare Coverage Database (MCD) Search Interqual Criteria Database

Behavioral Health Clinical Criteria & Guidelines

Optum Behavioral Health uses Clinical Criteria based on sound clinical evidence to make coverage determinations, as well as to inform discussions about evidence-based practices and discharge planning. In using its Clinical Criteria, Optum Behavioral Health takes individual circumstances and the local delivery system into account when determining coverage of behavioral health services. The following are the Clinical Criteria used by Optum Behavioral Health to make coverage decisions. Please note other Clinical Criteria may apply outside of or in addition to the following criteria due to superseding federal or state requirements, and/or specific contractual requirements.

For more information about coverage decisions or how to request an organization determination or appeal , please visit: Member Tools & Resources | KelseyCare Advantage