713-481-5347For Health Professionals
Contracted Provider Forms
- PlanLink Access Request Form
- 2024 Authorization Request Form
- Claim Submission Information
- Transition of Care/Continuity of Care Form
-
KelseyCare Advantage Prior Authorization List Archive
Claims Submission Information
All claims for authorized, covered services provided to eligible, Kelsey-Seybold assigned HMO, POS and EPO members must be submitted on a CMS 1500 form, a UB 04, or in an electronic format, as applicable. Claims submitted with ‘Unlisted Procedure Codes’ must include documentation supporting the use of that code for payment consideration. If necessary to determine if the claim is payable, Kelsey-Seybold may within thirty (30) days of receipt of a clean claim, request additional information from the treating provider.
For update to date claim filing directions please visit National Uniform Claim Committee - 1500 Instructions (nucc.org)
Effective 5-1-24: New Mailing Address for Claims
Mail Paper Claims to:
Kelsey- Seybold Clinic
Attn: Claims Department
P. O. Box 31031
Tampa, Florida 33631
Appeals mailing address:
Kelsey- Seybold Medical Group
P.O. Box 841209
Pearland, Texas 77584
KS Plan Administrators
P.O. Box 841649
Pearland, Texas 77584
Institutional Electronic Claims:
Payor ID: KELSI
Professional Electronic Claims:
Payor ID: KELSE
Become An Affiliate Provider
If you are interested in becoming a contracted provider with Kelsey-Seybold Clinic please submit a Letter of Interest (LOI).
Letter Of Interest (LOI) Requirements
Please include the following information in your LOI:
- a company overview
- services provided
- your location(s)
- geographical coverage areas
- specialty services
- medical staff roster, if applicable.
Letters can be submitted via:
Email: affiliateproviders@kelsey-seybold.com
Fax: (713) 442-2775
Kelsey-Seybold Clinic
Attn: Network Development
11511 Shadow Creek Parkway
Pearland, Texas 77584
Affiliate Provider Application Response Timeline
Provider selection is based on numerous factors. You will receive notification regarding the Plan's decision to enter into an agreement generally within six (6) weeks of submission of the LOI.