Form C-36/c-37 - Utilization Reviewclosure - Tennessee Bureau Of Workers' Compensation Page 2

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FORM C-36/C-37
C.
Retrospective Review
Diagnosis Code
.
.
Procedure
CPT Code
Identified Discrepancy Code
Cost
TOTAL SAVINGS
$
Comments
D.
Chiropractic Services
Diagnosis Code
.
.
Requested Service
Cost
Authorized
Identified Discrepancy Code
Savings
Service
TOTAL SAVINGS
$
Length of Treatment
(Number of Weeks)
Total Cost of Treatment
$
Comments
E.
Physical Therapy
Diagnosis Code
.
.
Procedure
CPT Code
Identified Discrepancy Code
Cost
TOTAL SAVINGS
$
Length of Treatment
(Number of Weeks)
Total Cost of Treatment
$
Comments
F.
No actions were taken.
G. Cost of Utilization Review
$
H. Reviewer’s Name
2
LB-0375 (
. 12/07)
RDA 10183
REV

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