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. Pre-admission Review Diagnosis Code _____._____. _________________________ CPT Code Requested length of stay ______________ Authorized length of stay ______________ Actual length of stay ______________ Identified discrepancy code ______________ In-Patient Savings $ _____________ Date / / - / / Comments ____________________________________________________________________ B. Concurrent Review Procedure Diagnosis Code _____._____. CPT Code Identified Discrepancy TOTAL SAVINGS Cost $ Comments ____________________________________________________________________ LB-0375 (REV. 12/07) 1 (see other side/next page) RDA 10183 American LegalNet, Inc. www.FormsWorkflow.com 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 Authorized Diagnosis Code _____._____. Identified Discrepancy Code Savings 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. No actions were taken. G. Cost of Utilization Review H. Reviewer’s Name _________________________________________________________________ LB-0375 (REV. 12/07) $________________________________________________________ 2 RDA 10183 American LegalNet, Inc. www.FormsWorkflow.com