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FORM C-35 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation Nashville, Tennessee 37243-0661 UTILIZATION REVIEW NOTIFICATION EMPLOYEE INFORMATION State File

How to fill out utilization review notification c

To fill out utilization review notification c, follow these steps:

1. Fill in the identification section: Provide your name, contact information, and any other requested details.
2. Identify the patient: Include the patient's name, date of birth, and medical record number.
3. Provide the payer information: Specify the insurance company or payer responsible for the patient's healthcare coverage.
4. Indicate the treating healthcare provider: Include the name, address, and contact information of the provider who is requesting the utilization review.
5. Describe the requested services: Clearly state the medical services or procedures that are being requested for the patient.
6. Provide diagnosis information: Include the primary diagnosis and any relevant secondary diagnoses to support the medical necessity of the requested services.
7. Provide the anticipated treatment plan: Detail the proposed treatment plan, including the frequency, duration, and expected outcomes of the requested services.
8. Include supporting medical documentation: Attach any relevant medical records, test results, or clinical notes that support the necessity of the requested services.
9. Obtain necessary signatures: Ensure that the utilization review notification is signed and dated by the requesting healthcare provider.

Utilization review notification c is required for healthcare providers who need to request the review of a specific medical service or procedure for a patient. It is typically used when seeking pre-authorization or determining medical necessity for insurance coverage. This notification helps ensure that the requested services meet the required criteria for reimbursement.

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What is utilization review notification c?

Utilization review notification c is a form that is used to notify the relevant authorities and stakeholders about the process and outcome of a utilization review for medical services.

Who is required to file utilization review notification c?

Healthcare facilities, such as hospitals or clinics, are typically required to file the utilization review notification c. This may vary depending on the specific regulations and requirements of the jurisdiction.

How to fill out utilization review notification c?

To fill out the utilization review notification c, healthcare facilities will need to provide the required information about the utilization review, including the details of the patient, the medical services in question, and the outcome of the review. The specific form and instructions for filling it out may vary depending on the jurisdiction and regulatory requirements.

What is the purpose of utilization review notification c?

The purpose of utilization review notification c is to ensure transparency and accountability in the utilization of medical services. It allows relevant authorities and stakeholders to be informed about the review process and outcome, and helps in monitoring and evaluating the appropriateness and quality of healthcare services provided.

What information must be reported on utilization review notification c?

The information that must be reported on utilization review notification c typically includes details such as the patient's demographics, the medical services being reviewed, the healthcare provider involved, the outcome of the review (e.g., approval, modification, denial), and any additional comments or supporting documentation as required by the jurisdiction.