If a Louisiana carrier or self-insured employer finds that a 1010 authorization request lacks the minimum information required by LAC 40:2715(C), it sends this one-page first request, checking which items are missing and explaining why. The health care provider responds in Section 3, either supplying the information or explaining why it was not provided. The authorization clock is suspended until the provider supplies it.
The carrier or self-insured employer completes Section 2. The health care provider completes Section 3, marking whether additional information has been provided and attaching it, or explaining why not.
Download the current version from the source each time; forms change without notice.
LWC Form 1010A - First Request
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Complete Section 3: mark that additional information has been provided and attach the supporting documentation, or mark that it has not and explain why. Then fax or email the response to the carrier and record the date in Section 4 of the 1010.
Yes. A first request suspends the authorization clock until the provider supplies the missing minimum information, so the carrier's five business days to answer the 1010 do not run while the 1010A is outstanding.