Utilization Review Closure Form Instructions

The State of Tennessee guidelines require Utilization Review (UR) providers be certified by accreditation from the Utilization Review Accreditation Commission (URAC), or be compliant with minimum UR standards.
Authority: Tennessee Code Annotated, Section 50-6-704, (Section 8 of chapter 812 of the Public Acts of 1992).

The original two-sided utilization review closure form should be submitted to the Tennessee Bureau of Workers’ Compensation following the conclusion of utilization review services.

  • Indicate the type of review(s) performed
  • List the primary ICD 9 code next to the type of review (for pre-admission review, list the primary admission diagnosis)
  • List other ICD 9 codes on the comment line
  • CPT codes should be documented

List the applicable discrepancy code from the list below when a discrepancy is found during a review. If there were no discrepancies, check the “no actions taken” field.

In addition to the reviewed information, all fields above letter “A” and below the letter “E” are required to be completed. The actual length and cost of physical therapy and chiropractic services must be documented regardless of findings.  

Discrepancy Codes

Code Number Code Description
01 Inappropriate level of service. 
02 Not medically indicated. 
03 Length of stay exceeds authorization. 
03.1 Length of stay exceeds authorization but is justified. 
03.2 Length of stay exceeds authorization and is not justified. 

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