Louisiana health care providers request prior authorization for treatment or testing under the Medical Treatment Schedule on this form, and the carrier or self-insured employer answers on the same document. The provider gives the diagnosis, CPT or DRG and ICD or DSM codes, the requested service and its reasons, and the minimum information required by LAC 40:2715(C). Silence past five business days counts as a denial.
The health care provider completes Sections 1 and 2 and certifies the date it was faxed or emailed. The carrier or its utilization review company completes Section 3, and later sections track first requests, suspensions and Medical Services determinations.
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Request of Authorization/Carrier or Self Insured Employer Response
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Five business days from submission. If the carrier or self-insured employer does not return the 1010 in that time, it is a deemed or tacit denial, which the provider or employee can dispute with the OWCA Medical Director on Form 1009.
The minimum information under LAC 40:2715(C): history to the level the Medical Treatment Schedule requires, physical findings and clinical tests, documented functional improvement from earlier treatment, test or imaging results, and a treatment plan stating the services requested with their frequency and duration.
Section 3 lets the carrier approve, approve with modifications, or deny because the request is not in accordance with the Medical Treatment Schedule or R.S. 23:1203.1(D), is not related to the work injury, or the claim is non-compensable. It returns the response to the provider, and to the claimant's attorney if denied or modified.