Medical Form Update (C-35A)
Attention Injured Workers, Adjusters, Insurers, Utilization Review Organizations, Providers, and Attorneys: We've updated our UR appeal form.Wednesday, March 09, 2022 | 11:19am
Form's Purpose
The state form C-35A is "pre-filled out" by insurance adjusters and given to all parties when a reviewed treatment is deemed medically unnecessary by the URO (Utilization Review Organization).
What Changed:
- Added a new form field (blank space) to include the claim supervisor's email address. We hope this will keep things from falling through the cracks and keep everyone informed.
- Updated the instructions to clarify that the insurance adjuster is responsible for pre-filling out the majority of this form.
- Updated the instructions for the submitter to know what all to include when submitting this form back to the Bureau.
Download File
Notice of Appeal Rights for a Utilization Review Denial:
https://www.tn.gov/content/dam/tn/workforce/documents/injuries/bureau-services-forms/c35a.pdf
Please update your systems to the new Form C-35A.