Utilization Review Closure {C-36-C-37}

FORM C-36/C-37 TENNESSEE DEPARTMENT OF LABO R AND WORKFORCE DEVELOPMENT Division of Workers Compensation Nashville, Tennessee 37243-0661 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 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 ofs savingincluding zero when applicable. Complete the no actions takenfield if there were no discrepancies. The actual cothst o and lefngphysical 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 descrepancy code ________________ In-Patient Savings $ _______________ Comments ___________________________________________________________________________________ B. Concurrent Review Diagnosis Code_____ ._____. Procedure CPT Code Identified Discrepancy Code Cost TOTAL SAVINGS $ Comments ___________________________________________________________________________________ (see other side) <<<<<<<<<********>>>>>>>>>>>>> 2C. Retrospective Review Diagnosis Code_____. _____. Procedure CPT Code Identified Discrepancy Code Cost TOTAL SAVINGS $ Comments ___________________________________________________________________________ D. Chiropractic Services Diagnosis Code_____. _____. Requested Service Cost Authorized Service Discrepancy Code Savings 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. Reviewers Name_________________________________________________________________ LB-0375 (rev.5/23)