How to Fill Out Louisiana LWC Form 1010: Sections and Insurer Response

To fill out Louisiana LWC Form 1010, gather the required clinical documentation, complete the provider, employee, and insurer sections with data that matches the carrier’s records exactly, enter CPT or DRG codes for every requested service alongside the ICD or DSM diagnosis codes, and submit the form directly to the insurer or self-insured employer. The payor then has five business days to approve, modify, or deny the request. The form is a prior-authorization request for non-emergency treatment that exceeds $750 per provider on a workers’ compensation claim, and it never goes to a state agency at this stage.

When You Need to Submit Form 1010

Louisiana caps non-emergency diagnostic testing and treatment at $750 per health care provider before prior authorization is required. Once your charges on a single claim approach that threshold, any additional non-emergency service needs the payor’s written consent on a completed Form 1010.¹ The $750 threshold applies to each provider separately, so a treating physician and a separate imaging center each have their own cap on the same claim.

Emergency procedures are exempt. Care needed immediately to prevent death or serious permanent harm can be delivered without waiting. Everything else beyond the cap runs through Form 1010: elective surgeries, specialist referrals, advanced imaging like MRIs, and extended physical therapy programs.

Documentation to Gather Before You Start

A Form 1010 submitted without the right supporting records will stall. Under Louisiana Administrative Code Title 40, Section 2715, every initial authorization request must include:²

Medical history to the level of the condition, consistent with the Louisiana Medical Treatment Schedule for the affected body area.
Physical findings and clinical test results documenting the current status of the injury.
Functional improvement from any prior treatment the patient has received.
Test and imaging reports supporting the need for the requested service.
A treatment plan naming the specific services, frequency, and duration being requested.

Follow-up requests after the initial authorization are lighter. A subsequent Form 1010 only needs updates to these categories rather than a full re-submission, but the updates must show the patient’s current status and explain why continued treatment is warranted. The Medical Treatment Schedule uses functional improvement as the benchmark, so documenting measurable progress (or explaining why progress has plateaued and what the next step addresses) is critical.

Before filling anything in, verify the claim number assigned to the injured worker and confirm the correct insurer or third-party administrator. A misdirected form burns through the five-day response clock while it sits in the wrong inbox.

Completing the Form Section by Section

The form is available for download on the Louisiana Workforce Commission website.³ Each section needs to be filled out precisely. Mismatched names and missing codes are among the most common reasons requests come back.

Provider Information

Enter the requesting health care provider’s name, address, phone, and fax number. This is the contact point the insurer will use to return the completed form, so make sure the fax number and email you monitor are the ones listed.

Employee Information

The injured worker’s information must match the insurer’s records exactly: full legal name, date of injury, and claim or policy number. A single transposed digit in the claim number can route the form to the wrong adjuster.

Insurer Information

Identify the payor, meaning the insurance carrier or self-insured employer, with current contact details. If you are unsure of the correct carrier, confirm with the employer or the adjuster of record before sending.

Requested Services and Codes

The clinical core of the form requires CPT or DRG codes for every service or procedure requested, paired with ICD or DSM diagnosis codes for the underlying condition. Be specific. A vague entry like “physical therapy” without the type of service, number of sessions, and duration gives the insurer grounds to deny or push back for more information. For routine office visits, the CPT codes covered on Form 1010 are limited to the 99201–99205 and 99211–99215 ranges.⁴

Description and Rationale

Tie the requested treatment directly to the Medical Treatment Schedule. If the schedule covers what you are requesting, reference the relevant section. If the treatment falls outside the schedule, you will need a stronger clinical rationale explaining why a variance is appropriate for this patient’s situation.

Where to Send the Form

Form 1010 goes directly to the insurer or self-insured employer, not to the Office of Workers’ Compensation. Each carrier sets its own intake method. LWCC, for example, accepts Form 1010 submissions by fax at (888) 560-5922 or by email at lwccur@lwcc.com.⁴ Other carriers use different fax numbers, email addresses, or electronic portals. Confirm the correct channel with the specific payor before sending. The five-business-day response clock starts when the carrier receives the form, so keep proof of delivery.

What the Insurer’s Response Looks Like

Once the insurer receives a properly completed Form 1010 with the minimum required documentation, it has five business days to respond.⁵ The insurer returns the form with Section 3 completed and one of three outcomes marked:

Approved. The requested treatment is authorized and you can proceed.
Approved with modification. Some services are authorized, or a different scope or duration is approved.
Denied. The request is rejected.

A denial or modification must include a written summary of reasons covering the clinical rationale, specific references to the Medical Treatment Schedule, and a Voluntary Reconsideration section with a phone number for someone with authority to reverse the decision.² The insurer must fax or email the completed form and the summary of reasons to the provider and the claimant’s attorney (if there is one), and mail a copy to the claimant that same business day.

Silence Counts as a Denial

A carrier that fails to return the Form 1010 with Section 3 completed within five business days is deemed to have denied the request.² A deemed denial carries the same legal weight as a written one.

If the Insurer Sends Back a Form 1010A

Instead of approving or denying, the insurer may find that your submission is missing minimum required documentation. It then sends back a Form 1010A, a formal notice that the authorization process is suspended until you supply the missing information.⁶ The 1010A identifies which elements of LAC 40:2715(C) were not met. This is not a denial. It pauses the clock until you respond with the requested records.

What Happens If You Skip Authorization

Providing non-emergency care beyond the $750 threshold without prior authorization is a financial risk for the provider, not the patient. Any fees above $750 for non-emergency services are not an enforceable obligation against the injured worker, the employer, or the insurer unless both the employee and payor agreed to the treatment.¹ A provider who skips the Form 1010 process and delivers $5,000 in treatment can only collect the first $750. The rest cannot be billed to the patient or recovered through the workers’ compensation system. Getting the form right the first time is far more efficient than trying to collect after the fact.

If Your Request Is Denied

Form 1010 handles the request itself; disputes go on a different track. If the request is denied, approved with modification, or deemed denied through non-response, the aggrieved party has 15 calendar days to file a Disputed Claim for Medical Treatment using Form 1009 with the Office of Workers’ Compensation Administration.⁷ The OWC Medical Director then reviews whether the requested treatment aligns with the Medical Treatment Schedule based on the record you submitted, which is another reason to make the original Form 1010 documentation as strong as it can be.

1
Justia. Louisiana Code 23-1142 – Approval of Health Care Providers; Fees
2
Cornell Law Institute. Louisiana Admin Code tit 40, I-2715 – Medical Treatment Schedule Authorization and Dispute Resolution
3
Louisiana Workforce Commission. LWC-WC-Form 1010 – Request of Authorization/Carrier or Self Insured Employer Response
4
Louisiana Workers’ Compensation Corporation. Utilization Review Rules
5
Louisiana State Legislature. Louisiana Code 23-1203.1 – Definitions; Medical Treatment Schedule; Medical Advisory Council
6
Louisiana Workforce Commission. Louisiana Workers’ Compensation Form 1010A
7
Louisiana Workforce Commission. Disputed Claim for Medical Treatment (1009)