Online Demonstration

Confirmation of Utilization Review Closure

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Employee Information
SSN ending in	6789	Date of Injury	05/05/2003
Sex	Female	DOB	01/01/1955
Utilization Review Information
Utilization Review Company		Company Name
TN ID Number		1234567
Physician(s)
Enter the overseeing physician's information.
Title		License Number
DDS		98765
Last Name		First Name
Sample		Joe
City		State
Cityville		Tennessee
Treating Facility		Sample Training Facility
Address Line 1		1234 Main Street
Address Line 2		Suite 1234
City		Nashville
State		TN
Zip		37219
Summary of Actions Taken by the Utilization Review Provider (Indicate each type of review performed).
Checked		Pre-admission Review
Diagnosis Code	1234.56789	CPT Code	ABC123
Requested length of stay		2 Weeks
Authorized length of stay		2 Weeks
Actual length of stay		2 Weeks
Date		FROM 02/03/2003 THRU 02/13/2003
Identified discrepancy code		A1B2C3
In-patient Savings		$514.23
Cost of Utilization Review	$300.23
Reviewer's Name	John Sample

Online Demonstration