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<Adjuster>

<Insurance carrier>
<planner>
RE: <claimant>
Claim #: <#>

RECOMMENDED PLAN OF ACTION


Date Prepared: <todays date>
Dear <adjusters first name>,
Thank you for the referral to ExamWorks Clinical Solutions. This plan of
action was developed based on a specialized clinician review of provided
medical records, pay history, pharmacy ledger and research related to the
accepted medical condition/diagnoses. Areas of impact are identified and
outlined below; the recommendations are based on accepted and recognized
standards of care and authoritative guidelines.
Clinical Assessment [drop down list]
Claimant at-risk due to multiple medications and increased occurrence
of side effects.
Potentially inefficient use of resources due to high cost non-prescription
combination drugs.
Inefficient use of health care resources due to brand name drug
prescribed when a generic version is available.
Inefficient use of health care resources due to drugs being prescribed
from the physicians office
Uncertainty of indication and relationship for a prescribed drug to the
work injury.
Unclear relationship of diagnostic tests to work injury.
Care potentially inefficient due to multiple health care providers
Frequency of treatment not supported by available records
Frequency of office visits not supported by available records
Care complicated due to social and/or psychological issues
Goals
< free text box >
Plan: [drop down menu to be added to]

An Rx Analysis: A Solution Center pharmacist (Doctor of Pharmacy)


reviews the records, identifies possible duplications, overlapping
medications, potential drug interactions, and develops a suggested
medication plan with a cost comparison to show potential savings.
Outreach to the treating physician by a Doctor of Pharmacy (PharmD)
to discuss the suggestions in the Rx Analysis.

]
<free text box>
Ex Parte Communication Notice:
By requesting Complex Claim services it may be necessary for ExamWorks
Clinical Solutions to communicate with the claimants medical providers. We
assume you have authorization under the law or have obtained proper
written authorization from the claimant which allows ExamWorks Clinical
Solutions to communicate with the claimants medical providers. Please
forward a copy of signed authorizations, if applicable. If you do not have
authorization, please advise us immediately. If authorization is
necessary, ExamWorks Resolution Services are available to obtain the
executed authorization form from the claimant or through their attorney. Your
dedicated ExamWorks Account Executive can provide pricing information for
these services.
[Populate text box with:]
Please advise if you would like us to follow up on the recommendation for
<service product>. Contact your Account Executive, <AE name>, at <AE
phone> for further details and pricing information.
OR
The (service product) will be initiated. You will receive a report in thirty days
with a progress update.
If you have any questions or concerns, please contact me.
Thank you for the referral.
< File Owners name>
ExamWorks Clinical Solutions
Phone: <#>
Fax: (866) 883-1867
<File owners email address>
cc: <adjusters name and email address>
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