Form C-36/c-37 - Utilization Reviewclosure - Tennessee Bureau Of Workers' Compensation

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FORM C-36/C-37
TENNESSEE BUREAU 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.
Pre-admission Review Diagnosis Code
.
.
CPT
Code
Requested length of stay
Authorized length of stay
Actual length of stay
Date
/
/
-
/
/
Identified discrepancy code
In-Patient Savings
$
Comments
B.
Concurrent Review
Diagnosis Code
.
.
Procedure
CPT Code
Identified Discrepancy Code
Cost
TOTAL SAVINGS
$
Comments
(see other side/next page) RDA 10183
1
LB-0375 (
. 12/07)
REV

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