Free APPENDIX A - Tennessee

FORM C-36/C-37 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002 UTILIZATION REVIEW CLOSURE

EMPLOYEE INFORMATION State File # _____________ Date of Injury____________ Social Security # ______________ Claimant _________________________________ DOB Sex ___________ EMPLOYER INFORMATION FEIN: _________________ Employer: ___________________________________________ Street: _______________________ City: State: Zip: __________ INSURER INFORMATION Insurer: ___________________________________________________________________ Insurer Address:________________________________________________________________ Insurer Claim #: _________________________ Policy Number: ___________________ UTILIZATION REVIEW INFORMATION Utilization Review Company __________________________________ TN ID# __________ License Number Healthcare Provider ________________________ MD/Chiro/DO ______________________ Treating Facility ___________________________ City _____________________________ Address _______________________________________________________________
Summary of Actions Taken by the Utilization Review Provider (Indicate each type of review performed. List the amount of savings including zero when applicable. Complete the "no actions taken" field if there were no discrepancies. The actual cost and length of physical therapy and chiropractic services must be documented even if there are no savings).

A. Code

Pre-admission Review Diagnosis Code _____._____. _________________________ CPT Requested length of stay Authorized length of stay Actual length of stay Identified discrepancy code In-Patient Savings ______________ ______________ ______________ ______________ $ _____________ Diagnosis Code _____._____. CPT Code Identified Discrepancy Code Cost Date / / / /

Comments ____________________________________________________________________ B. Concurrent Review Procedure

TOTAL SAVINGS
LB-0375 (REV. 12/07)

$
(see other side/next page) RDA 10183

Comments ____________________________________________________________________
1

FORM C-36/C-37 C. Retrospective Review Procedure Diagnosis Code _____._____. Identified Discrepancy Code Cost

CPT Code

TOTAL SAVINGS

$

Comments ___________________________________________________________________________ Chiropractic Services D. Requested Service Cost Diagnosis Code _____._____. Identified Discrepancy Code Savings

Authorized Service

TOTAL SAVINGS Length of Treatment Total Cost of Treatment ________________ $_______________ (Number of Weeks)

$

Comments ___________________________________________________________________________ E. Physical Therapy Procedure Diagnosis Code _____._____. Identified Discrepancy Code Cost

CPT Code

TOTAL SAVINGS Length of Treatment Total Cost of Treatment ________________ $_______________ (Number of Weeks)

$

Comments ___________________________________________________________________________ F. G. H. No actions were taken. Cost of Utilization Review $________________________________________________________

Reviewer's Name _________________________________________________________________
2
RDA 10183

LB-0375 (REV. 12/07)