Utilization Review Rules

  1. Who created the new Utilization Review (UR) rules?
  2. Who is the LWC?
  3. Who is LWCC?
  4. When did the UR rules go into effect?
  5. Where can a healthcare provider get an LWC Form 1010 & 1010 A?
  6. How does a healthcare provider send an LWC Form 1010 & 1010 A to LWCC?
  7. What information is needed with the LWC Form 1010?
  8. Should office visits be requested on an LWC Form 1010?
  9. What medical treatment has to be requested by LWC Form 1010?
  10. Who files the LWC Form 1010 to request durable medical equipment, physical therapy and occupational therapy?
  11. How are hospital discharges with request for durable medical equipment, home health, and physical/occupational therapy to be handled?
  12. How are disputes regarding the denials of the requested treatment handled?
  13. Where can I get an LWC Form 1009?
  14. Where can I get a copy of the medical treatment schedule?

1. Who created the new Utilization Review (UR) rules?

The new UR rules were adopted by the Louisiana Workforce Commission (LWC) Office of Workers Compensation Administration (OWCA) under LAC 40: I. 2701

2. Who is the LWC?

The Louisiana Workforce Commission (LWC), formerly known as the Louisiana Department of Labor, is the state agency over the Office of Workers’ Compensation Administration. LWC is not affiliated with LWCC.

The LWC Office of Workers’ Compensation Administration can be contacted at:
Office of Workers’ Compensation Administration
P.O. Box 94040
Baton Rouge, LA 70804-9040
Telephone: (225) 342-7555
Fax: (225) 342-5665
owca@lwc.la.gov

**If you have questions about the utilization rules not specifically related to an LWCC claim or want more information regarding the medical treatment guidelines and the UR process, please visit the Louisiana Workforce Commission’s FAQs at the below link:

www.laworks.net/Downloads/OWC/MedicalGuidelines_MedicalTreatmentGuidelineFAQs.pdf

3. Who is LWCC?

LWCC (Louisiana Workers’ Compensation Corporation) is a private, nonprofit mutual insurance company. LWCC is the largest writer of workers’ compensation insurance in the state of Louisiana. LWCC is not a state agency and does not administer the rules or laws governing workers’ compensation in Louisiana.

4. When did the utilization review rules go into effect?

April 20, 2012

5. Where can a healthcare provider get an LWC Form 1010 & 1010 A?

www.laworks.net/Downloads/OWC/1010form.pdf
www.laworks.net/Downloads/OWC/1010Aform.pdf

6. How does a healthcare provider send an LWC Form 1010 & 1010 A to LWCC?

All 1010s and 1010As must be sent to either LWCC’s centralized fax or email: Fax #: (225) 231-8415
Email: lwccur@lwcc.com

7. What information is needed with the LWC Form 1010?

According to Section 2 of the 1010 form, the following information is required at a minimum:

  • History provided to the level of condition and as provided by medical treatment schedule
  • Physical findings/clinical tests
  • Documented functional improvements from prior treatment
  • Test/imaging results
  • Treatment plan including services being requested along with the frequency and duration

8. Should office visits be requested on an LWC Form 1010?

A provider must submit a Form 1010 to the insurer requesting authorization to continue treating the injured worker once the initial $750 limit on nonemergency care has been reached. This initial 1010 must contain documentation and records which comply with the Louisiana Medical Treatment Schedule, known as the medical treatment guidelines.

Once the initial 1010 is approved by the insurer, the provider will not be required to submit a Form 1010 for additional office visits during the 12 months following the date of accident, or 12 visits, whichever comes first. The 12 visits includes those billed prior to the $750 limit.

It is important to note that this provision does not apply to any other services provided and billed as part of any of the 12 visits, such as X-rays, procedures, or referrals for diagnostics or other treatment. The current Form 1010 process will continue to apply to services other than office visits. The only codes covered in the 1010s for routine office visits are 99201–99205 and 99211–99215.

After the initial 12-month period, the provider must submit a new Form 1010, which conforms to the requirements of the Medical Treatment Schedule, to request authorization for additional office visits. If approved, the insurer must authorize four additional visits. More than four visits can also be approved to be completed within a specified time frame.

9. What medical treatment has to be requested by LWC Form 1010?

All medical treatment, care and services must be requested on a 1010 form except prescription medications that are handled through our pharmacy benefit manager in conjunction with the medical treatment guidelines. All other prescription medication requests must be on a 1010 form.    

10. Who files the LWC Form 1010 to request durable medical equipment, physical therapy and occupational therapy?

 The treating healthcare provider is responsible for completing the 1010 form for request for any durable medical equipment, physical therapy or occupational therapy.  

11. How are hospital discharges with request for durable medical equipment, home health, and physical/occupational therapy to be handled?

All anticipated requests for services upon hospital discharge should be submitted in advance along with the requested service, such as surgery, to avoid delayed approval upon discharge. Whether the service is requested in advance or upon discharge, all requested services should be on a 1010 form. 

12. How are disputes regarding the denials of the requested treatment handled?

If a dispute regarding the UR decision arises, the aggrieved party has 15 calendar days to file an LWC Form 1009 with the OWC. Once filed, the OWC medical director has 30 calendar days to issue a decision.

If either party disagrees with the medical director’s decision, the parties have 15 calendar days to file an LWC Form 1008 for judicial review which will then be heard through an expedited hearing in 15 to 30 calendar days.

13. Where can I get an LWC Form 1009?

www.laworks.net/Downloads/OWC/1009form.pdf

14. Where can I get a copy of the medical treatment schedule?

www.laworks.net/WorkersComp/OWC_MedicalGuidelines