The Louisiana Request of Authorization/Carrier or Self Insured Employer Response — Form 1010 is a document used by employers or carriers in the state of Louisiana to respond to requests for authorization of treatment for an accident or illness. The form is used to verify the identity of the requesting party, the coverage of the requested medical treatment and the amount of benefits available. There are two types of Form 1010: the Carrier Response and the Self Insured Employer Response. The Carrier Response is used when a third-party carrier is providing insurance coverage for the employee. The Self Insured Employer Response is used when the employer is providing its own coverage. The form includes sections for the employer or carrier to provide contact information, the policy number, the date of the accident or illness, the name of the doctor or facility providing treatment, the type of treatment and the amount of benefits available. It also includes a section for the employer or carrier to sign off on the request.
Louisiana Request of authorization/carrier or self insured employer response - Form 1010
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How to fill out Louisiana Request Of Authorization/carrier Or Self Insured Employer Response - Form 1010?
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FAQ
The health care provider seeking authorization to exceed the $750 statutory limit for medical services must submit a request for such authorization to the employer or its workers compensation insurer on an Form LWC-WC 1010 (Request of Authorization/Carrier or Self Insured Employer Response).
Although you are pursuing a claim, you are still an employee of this employer and you should continue to receive benefits just as you always have. You should pay the same health insurance premiums, if any, that you are normally required to.
Louisiana Revised Statutes (LA Rev Stat) §61 states you cannot be terminated because you have made a workers' compensation claim. However, you may lose your job while on workers' compensation if you are no longer able to perform the duties that your job requires.
HOMEBUYER ASSISTANCE PROGRAM STATEMENT AND EXPLANATION OF FACTS (FORM 1010)
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.
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.