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Claims

Easy Ways to Report Claims

LWCC gives you several quick, easy ways to report claims. We will take care of meeting filing requirements and deadlines with state or federal agencies on your behalf. You may no longer submit a report of a workplace injury or illness through the Louisiana Workforce Commission’s Office of Workers’ Compensation Administration. Claims must be filed directly through your workers’ compensation insurance carrier.

Report injuries within one hour, even if you do not have all the necessary information regarding the claim. Every moment you delay reporting an injury can substantially increase claim costs, which potentially can drive up your premium.

  1. Online (interactive.lwcc.com)
    The fastest way to report your claim is through LWCC’s password-protected website, LWCC Interactive.* Log in to LWCC Interactive and select the “Claims Info” navigation tab. From the drop-down menu, select “Report a Claim.” Simply complete the information about the injury, and we’ll do the rest. An LWCC claims service professional will call you within 24 hours to discuss the injury.
  2. By Phone (800-395-0303)
    Our toll-free, 24-hour Claims Reporting Hotline puts you in touch with a friendly claims service professional who will take your information, handle the administrative paperwork and process the claim for you. Even if you do not have all of the details about an incident, early reporting is critical.
  3. By Email (onlineclaims@lwcc.com)
    Email is another quick method of claim reporting. Simply fill out the Louisiana Workforce Commission’s Office of Workers’ Compensation’s First Report of Injury or Illness form (LWC-WC IA-1) and email the report to onlineclaims@lwcc.com. An LWCC claims service professional will then call you within 24 hours to discuss the injury. NOTE: If you are sending attachments with the form, include the injured employee’s name and your policy number for identification purposes.
  4. By Fax (225-231-0951)
    If you prefer to fill out the Louisiana Workforce Commission’s Office of Workers’ Compensation’s First Report of Injury or Illness form (LWC-WC-IA-1), you may fax the report to LWCC. You may no longer submit this form to the Office of Workers’ Compensation. An LWCC claims service professional will then call you within 24 hours to discuss the injury. NOTE: If you are sending attachments with the form, please include the injured employee’s name and your policy number for identification purposes.

* To sign up for LWCC Interactive, download the registration form here.

Reporting Purposes Only (RPO) Claims

When you report minor injuries that don’t involve medical expenses or lost time, your premium will not be adversely affected. However, if the injury grows more serious than anticipated, LWCC has the necessary information to begin handling the claim. That is why it is important to report even minor injuries that do not require professional medical intervention.

In order to help us do a better job of tracking and handling claims that originate as minor injuries, a claims representative will enter the reported injury into our computer system for reporting purposes only. RPOs will appear on the policyholder’s loss run, but because there are no expenses associated with these claims, they will not affect the policyholder’s premium experience modifier (E-mod).

The stipulations for an injury to qualify as an RPO claim are as follows:

  1. The injury must require no follow-up treatment by a hospital or medical provider and result in no time lost from work.
  2. At the time the policyholder reports the accident, it must be specifically stated that the claim is for “reporting purposes only.”
  3. If a medical bill is received by LWCC on an RPO claim, LWCC will contact the policyholder to investigate the claim and determine whether the claim status should be changed from RPO to an active claim.
  4. LWCC reserves the right to decide the future status change of any RPO claim. However, if LWCC believes a claim needs to be converted to an active claim, it will not be done without first discussing the reasons with the policyholder.

This program is a safeguard for the policyholder to be certain that all bases are covered in case the minor injury turns into something more serious than originally anticipated.

Medicare Reporting

Medicare reporting is imposed through Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA). Medicare is always secondary to workers’ compensation insurance and it is the carrier’s responsibility to protect Medicare’s interest. In order to protect Medicare’s interest, LWCC has had a Medicare Set Aside (MSA) program in place since 2001. Under the new law, Medicare requires strict reporting to identify money previously paid by Medicare that a primary payer should have paid.

LWCC is the responsible reporting entity for claims where there is policy coverage. The LWCC program protects our policyholders if the policyholder reports ALL claims to us, including RPO claims. The policyholder also has to be in compliance with our RPO program and should not make any medical payments on RPO claims after one year from the date of accident. If the policyholder does not report all claims to LWCC or if the policyholder is not in compliance with our RPO program, then the policyholder is acting as self-insured, and the policyholder is the responsible reporting entity. The policyholder could also be subject to fines of up to $1,000 per day per claim for failure to report.

Our Claims Team

We understand that until your employee is back at work, costs can continue to impact your bottom line and your premium. The goal of our claims team is to help get your employees well and back to work as soon and safely as possible. Because no two claims are alike in their scope and severity—from reporting purposes only (RPO), to medical only, to lost time, to catastrophic—it takes a team of experts who specialize in the unique aspects of each claim.

Here’s what you can expect from our claims team and the services they provide. 

Medical Only and Maintenance (M&M) Representatives

Medical-only claims are those in which a workplace injury or illness requires professional medical attention but does not result in the injured worker losing time away from work. In these cases, any appropriate and necessary care by a medical provider is reimbursed. Maintenance claims are those claims that extend for a longer period of time and may involve lost-time and indemnity benefits being paid to the injured worker.

Investigative Claims Representatives (ICRs)

When a more serious claim occurs that will necessitate the injured worker losing time away from work, or if a claim is questionable, an investigative claims representative (ICR) will become involved. LWCC’s claims representatives are based in Louisiana, which means quicker response and more personalized attention. Our investigative claims representatives are trained to conduct thorough, on-site investigations on lost-time claims. When a claim is reported, an ICR will:

  • Contact the policyholder within three hours after LWCC receives notice of the claim,
  • Contact the injured worker within 24 hours after the claim is received by LWCC, and
  • Schedule a field investigation the same day that contact is made or the closest mutually agreed upon date.

The ICR will gather information about the circumstances of the accident, obtain statements from any witnesses and gather evidence to determine if a claim is compensable.

Return-to-Work (RTW) Representatives

Our claims team’s return-to-work representatives assist employers in helping their injured workers get back to work as quickly and safely as possible. In addition to our in-house RTW representatives, LWCC’s return-to-work program includes WorkAction and our occupational medicine network, OMNET®.

  • WorkAction—The key to getting your injured employee back to work is early intervention. Our WorkAction return-to-work program capitalizes on the window of opportunity right after an employee is injured to help create a return-to-work plan that works for you. The program utilizes vocational rehabilitation specialists who help injured employees get back to work by providing on-site job analyses, recommend modified or transitional duty alternatives to ease the injured worker back into the workforce while saving the employer costs associated with lost-time claim absenteeism. Here’s what you can expect:
    1. Site Visit—A vocational rehabilitation consultant will visit your worksite to analyze the employee’s current job and help identify appropriate transitional duty work.
    2. Job Analysis—The analysis includes a written report as well as photographs of the job being performed. The job analysis is forwarded to the treating physician for review.
    3. Physician Review—A physician will review the analysis and make a recommendation about the employee’s ability to return to work, along with any restrictions.
    4. Follow Up—LWCC will follow up to help facilitate return-to-work transitional duty based on the physician’s recommendations.
  • OMNET®—LWCC also better manages lost workdays using OMNET®, our statewide network of more than 2,000 doctors, hospitals, and other health-care practitioners who share our return-to-work philosophy. When employees use OMNET®, they get the best care possible for a faster recovery and return to work, and you get lower claims costs.

Claims Specialists (CS)

Most employees view their jobs as a second home, a network of friends that provide emotional support. That’s why a tragedy at work, such as a serious injury or death, can be devastating to co-workers. LWCC responds to serious or catastrophic claims with specialized service, including representatives on call 24 hours a day, worksite counselors for your employees, and a claims specialist for face-to-face meetings with you, the medical team, the injured employee and family members.

Recovery Specialists

Our claims recovery specialists are experts who pursue at-fault third parties to recoup your claims costs, a process known as subrogation. We also seek reimbursements from the Second Injury Fund, a state program that reimburses employers or, if insured, their insurance carriers for part of the workers’ compensation costs in certain instances when an employee with a preexisting permanent partial disability is injured on the job. Quite often many employers are reluctant or will not hire employees with a preexisting permanent partial disability because they fear an increase in workers’ compensation insurance costs. The Second Injury Fund is designed to encourage employers to hire such employees by reimbursing the employer or its insurer for part of the compensation costs, if certain conditions are met, when such an employee is injured on the job.

Occupational Medicine and Medical Services

Occupational Medicine

Occupational medicine is the specialty focused on work-related health care. Whether your organization is large or small, the health of your employees has a direct impact on the health of your business. Accidents, illnesses, sick days, and time lost all affect business efficiency, productivity and profit.

LWCC’s occupational medicine department is dedicated to promoting the health of workers through preventive medicine, appropriate clinical care, and education. LWCC’s occupational medicine team is comprised of experts who oversee the medical care of job-related injuries and illnesses, minimize time loss, institute rehabilitation and return-to-work methods, contain costs, and facilitate well-managed care through our occupational medicine network, OMNET®.

Medical Director

LWCC’s medical director is responsible for providing medical support for programs involving claims management, utilization review, and medical networks. The medical director assists LWCC as it continues to develop and implement key strategic initiatives, including medical treatment guidelines. In addition, the medical director serves as a resource for LWCC, its policyholders, and its provider network to improve patient outcomes.

Client Relations Representatives

LWCC’s client relations representatives (CRRs) provide relevant information about ways to lower your claims costs. CRRs can help you coordinate care with OMNET® providers to facilitate quick, effective care for injured employees. They also are available to help you create a post-accident drug screening program, explain the Second Injury Fund and how it can benefit you, provide instruction on accessing LWCC Interactive’s wealth of helpful features and resources, and provide many other services at no additional charge.

Medical Services

LWCC’s medical services team includes registered nurses who manage the medical aspects of a claim and assist injured employees obtain quality care in a timely fashion utilizing clinical and cost-containment programs. This team of medical professionals has extensive clinical experience, diagnostic and procedural coding expertise, and knowledge of injury and disability processes to make decisions on the appropriate use of medical resources.

Medical Services Supervisor

The medical services supervisor oversees clinical services programs within LWCC’s occupational medicine department including utilization review, pharmacy management, durable medical equipment services, and cost-containment programs. The medical services supervisor works with the occupational medicine manager to develop strategies and procedures for LWCC’s clinical and cost-containment programs.

Medical Services Coordinator

The medical services coordinator assesses, evaluates, and coordinates medical management of injured workers while directing them in the occupational medicine network and, ultimately, returning them safely back to work. The medical services coordinator ensures that LWCC’s clinical and cost-containment programs provide quality care to injured workers in a timely fashion. They utilize clinical experience, diagnostic and procedural coding, and knowledge of injury and disability processes to make decisions on the appropriate use of medical resources.

Provider Relations Coordinator

LWCC provider relations coordinator is responsible for first-level reviews of requests for assigned durable medical equipment (DME) and assists the pharmacy services coordinator in the administration of the drug utilization review (DUR) program. The provider relations coordinator coordinates activities with the pharmacy benefits management company, pharmacists, policyholders, claims staff, injured employees, and information systems personnel to assure adherence to the DUR program’s policies and procedures.

Pharmacy Services Coordinator

The pharmacy services coordinator is primarily responsible for first-level reviews of the workers’ compensation DUR programs and working with the pharmacy benefits manager (PBM), pharmacists, physicians’ staffs, claims staff, injured employees, policyholders, information systems personnel, and pharmacy network representatives to assure adherence to DUR policies and procedures. The pharmacy services coordinator also reviews durable medical equipment requests requiring prior authorization and secures all required medical and claims information to support approval of medical necessity.

Utilization Review and Medical Bill Review Specialists

Backed by physicians, nurses, physical therapists and chiropractors, LWCC reviews requests for medical treatment to ensure they provide the care necessary for optimum recovery. Medical bills are also analyzed to make sure charges are appropriate and correct.

Frequently Asked Questions about the Medical Treatment Guidelines (MTG)

In 2009, the Louisiana Legislature passed RS 23:1203.1 which provided the process of adopting a medical treatment schedule with the purpose of assisting with the decision-making process regarding proposed medical treatment for the injured worker. The medical treatment guidelines became effective July 13, 2011.

A copy of the MTG can be found on the Louisiana Workforce Commission’s website, www.laworks.net. The medical treatment guidelines can be located on the homepage under the “Businesses” tab then “Workers’ Compensation.”

All medical providers and insurance carriers are expected to comply with the MTG. 

Effective April 20, 2012, the healthcare provider (HCP), when seeking authorization to exceed the $750 statutory limit for medical services, completes the LWC-WC Form 1010–Request of Authorization/Carrier or Self-Insured Employer Response form.

The health-care provider (HCP), when seeking authorization to exceed the $750 statutory limit for medical services, completes the LWC-WC Form 1010. Section #1 and #2 of the LWC-WC Form 1010 must be completed by the requesting health-care provider. The 1010 Form and all supporting medical documentation are faxed to the C/SIF and/or the designated utilization review (UR) representative. The C/SIF must respond in five business days by returning the Form 1010 to the requesting HCP with their decision determination designated in Section 3.

The C/SIF or UR representative will initiate the LWC-WC Form 1010A when the medical documentation submitted with the Form 1010 does not sufficiently provide the necessary information to complete the review of the requested medical services. The HCP must respond to the request within ten business days from the date of receipt. Failure to submit the requested information shall result in a withdrawal of the request for authorization.

The forms are posted on the Louisiana Workforce Commission’s website, www.laworks.net. You can access the form from the numerical listing by clicking on “Downloads,” then on “Workers’ Compensation,” then “Forms–Numerical.”

For any dispute as to whether the recommended care, services or treatment is in accordance with the medical treatment schedule, or whether a variance from the medical treatment schedule is reasonably required, any aggrieved party shall file an LWC-WC Form 1009 Disputed Claim for Medical Treatment appeal with the Office of Workers’ Compensation Administration medical director.

The LWC-WC Form 1009 must be completed and submitted, via mail, to the OWCA medical director along with the LWC-WC Form 1010, Form 1010A (if applicable), and supporting medical documentation.

The LWC-WC form must be filed within 15 calendar days of the date denial by the C/SIF or the date the denial was received. The medical director shall render a decision as soon as is practicable, but in no event, not more than 30 calendar days from the date of filing.

A COPY OF THE COMPLETED 1009 MUST BE MAILED TO ALL INVOLVED PARTIES.

The form is posted on the Louisiana Workforce Commission’s website, www.laworks.net. You can access the form from the numerical listing by clicking on “Downloads,” then on “Workers’ Compensation,” then “Forms–Numerical.”

The statute states “any aggrieved party” shall file, within 15 calendar days, an appeal with the OWCA medical director. Aggrieved party is defined as “a person whose personal or property rights are adversely affected by a judgment or decree of a court.”

The LWC-WC Form 1009 must be received in the OWCA Medical Services Section no later than 15 calendar days from the date on the written denial letter issued by the C/SIF. 

In addition to the completed LWC-WC Form 1009, the following information is necessary: 

  • Copy of the LWC-WC Form(s) 1010 and 1010A
  • Copy of the peer review denial from the C/SIF
  • Copy of the medical record(s) substantiating the medical necessity of the requested services

Requests submitted without the supporting documentation as stated above will be returned to the requesting party. Any LWC-WC Form 1009 with incomplete information will also be returned to the requesting party.

Any party feeling aggrieved by the determination of the medical director shall seek a judicial review by filing Form LWC-WC-1008–Disputed Claim for Compensation with the appropriate hearing office within 15 days of the date said determination is mailed to the parties. The filed LWC-WC-1008 shall include the following:

  • Copy of the Form LWC-WC-1009–Disputed Claim for Medical Treatment 
  • Copy of the decision of the medical director 

A party filing such appeal must simultaneously notify the other party that an appeal of the medical director’s decision has been filed. The decision of the medical director may be overturned when it is shown by clear and convincing evidence that the decision of the medical director was not in accordance with the provisions of the Louisiana Workers’ Compensation medical treatment guidelines.

Yes. Even if the recommended medical treatment is in compliance with the MTG, all medical services exceeding the statutory limit of $750 will require the prior approval from the C/SIF as stated in the Workers’ Compensation Statute (R.S. 23:1142).

In 2009, the Louisiana Legislature passed RS 23:1203.1 which provided the process of adopting a medical treatment schedule with the purpose of assisting with the decision-making process regarding proposed medical treatment for the injured worker. The medical treatment guidelines became effective July 13, 2011.