Utilization Review (UR) Rules
The Utilization Review Rules that have been in effect since 2012 when adopted by the Louisiana Workforce Commission (LWC) Office of Workers Compensation Association (OWCA) under LAC 40: I. 2701. Louisiana Workforce Commission (LWC) is the state agency over the Office of Workers Compensation Association (OWCA). LWC is not affiliated with 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.
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 the accident, or 12 visits, whichever comes first. The 12 visits include 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.
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. To request durable medical equipment, physical therapy, and occupational therapy, the treating healthcare provider is responsible for completing and filing a Form 1010. Services dealing with hospital discharges with a request for durable medical equipment, home health, and physical/occupational therapy should be submitted in advance along with the requested service, such as surgery, to avoid delayed approval upon discharge.
If a dispute regarding the Utilization Review arises, the aggrieved party has 15 calendar days to file an LWC Form 1009 with the Office of Workers Compensation (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.
Upon completing a Form 1010, 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
To find a LWC Form 1010 and 1010A:
To send an LWC Form 1010 and 1010A to LWCC, forms must be sent to either LWCC’s centralized fax or email:
- Fax #: (888) 560 - LWCC (5922)
- Email: email@example.com
Copy of the medical treatment schedule:
LWC Office of Workers’ Compensation Administration contact information:
P.O. Box 94040
Baton Rouge, LA 70804-9040
Telephone: (225) 342 - 7555
Fax: (225) 342-5665
**If you have questions about the utilization rules not specifically relates 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.
Frequently asked questions
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