Complaint and Appeal Procedures
For general complaints, disputes or appeals, a party should contact Majoris Health Systems either by letter, email or by telephone. All complaints and disputes must be submitted within 90 days of the date of the disputed action.
The complaint should be mailed to:
Majoris Health Systems
Employee Complaint Department
PO Box 1728
Lake Oswego, OR 97035
877-304-9526
E-mail: [email protected]
Majoris Health Systems will acknowledge receipt of the complaint by letter within seven (7) calendar days and send an acknowledgment letter that will include a description of the complaint procedures, time frames and a one-page complaint form for the appealing party to complete if the complaint is received verbally. At that time a request will be made for any additional information that may be warranted to process the dispute. We are always available to discuss any of these items with you if you so wish.
After the network has investigated a complaint, Majoris shall issue a resolution letter to the complainant no later than the 30th calendar day after the network receives the written or oral complaint.
If the complainant is dissatisfied with the resolution of the complaint or the process, the complainant may file a complaint with the Texas Department of Insurance.
Majoris Health Systems shall not engage in any retaliatory action against an employee, employer or provider because the employee, employer, provider or any other person acting on behalf of the employer or employee has filed a complaint against the network.
Adverse Determinations Utilization Review (Denials)
Adverse determination means a determination, made through Majoris Health Systems Utilization Review or Retrospective Review, that the health care services furnished or proposed to be furnished to you are not medically necessary or appropriate
Appeals arising from decisions made in the service utilization review process or quality assurance process must be made orally or in writing. The appeal or complaint may be made by the patient or someone acting on their behalf, or by the patient’s physician or health care provider.
When a medical dispute arises, it is referred by the Majoris Medical Director to a member of the Medical Review Committee (MRC). This Committee is comprised of physicians appointed by Majoris with appropriate expertise and specialties to review the treatment issue(s) in dispute and will not include the physician who made the original decision. The Committee member will review the medical treatment issue and make a determination whether to uphold the decision, obtain additional information or reverse the decision. Anytime additional medical information is required or obtained through the reconsideration process, it will be included in the review. If the committee member determines an actual patient evaluation is required to determine the outcome of the dispute, successful completion of the reconsideration process is predicated on the injured worker participating in the suggested evaluation. The reconsideration process will be completed within 30 days of the date that Majoris receives the request. At the completion of the reconsideration process, Majoris will notify all parties in writing of the decision. Such notice will include an explanation of the reasons for the decision, including any medical or clinical basis for the decision, the credentials of any medical provider consulted in the process, and the state/states of licensure for those providers. The parties will also be advised of the right to seek review of a denial by an Independent Review Organization. Such review may be requested through the completion of the forms allowing for the request of an Independent Review, which are included with this notice. The forms are also available on the Texas Department of Insurance website: www.tdi.state.tx.us or by sending a written request to:
HMO Division
Mail Code 103-6A
Texas Department of Insurance
P.O. Box 149104
Austin, TX 78714-9104
A request for an Independent Review must be filed no later than the 45th calendar day after the denial of reconsideration.
If you have any questions or need assistance in completing this form, you may contact Majoris Health Systems at the number below or contact the Texas Department of Insurance at the number provided on the form.
Majoris will promptly notify the Texas Department of Insurance when there has been a request for Independent Review. Notice will be made via electronic transmission and will be on the form required by the Texas Department of Insurance. The Utilization Review Agent may access the Texas Department of Insurance on working days between 7:00 a.m. and 5:00 p.m., Central Standard Time, Monday through Friday, to obtain assignment of an Independent Review Organization.
The Texas Department of Insurance will then advise Majoris and the patient of the Independent Review Organization assigned to the case. Within three days of that notification, Majoris must provide the following to the Independent Review Organization:
- All relevant medical records relating to the issue in dispute
- Any documents relied upon for the Utilization Review decision by Majoris
- A copy of the notification of the results of the Internal Review by Majoris
- Any information provided to Majoris to support the appeal
- A list of names and phone numbers of any healthcare provider who has provided treatment and/or may have records relevant to the appeal
Majoris will be bound by the decision of the Independent Review Organization regarding medical necessity. Majoris will pay for the Independent Review, but may charge the fee back to the payor, depending on the individual carrier contract.
Special Appeal Rights
Parties will be entitled to expedited reconsideration procedures for denials of preauthorization of treatment involving post-stabilization treatment, life threatening conditions, or denials of continued stays for hospitalized employees. Such requests will be reviewed in the same manner as listed above, but a response will be provided within one working day from the date of receipt of all information necessary to complete the reconsideration.
A patient with a life-threatening condition is not required to complete the reconsideration process, but may proceed directly to a request for independent review. The enrollee, person acting on behalf of the enrollee, or the enrollee’s provider of record shall determine the existence of a life-threatening condition on the basis that a prudent layperson possessing an average knowledge of medicine and health would believe that his or her disease or condition is a life-threatening condition.
If you believe you qualify and want to request review by an Independent Review Organization, you may do so at no cost to you. The Texas Department of Insurance will randomly assign an Independent Review Organization to your case and will notify us within one day of that assignment. We will then provide all of the necessary medical records for your case to the Independent Review Organization for their review.
Appeals of Adverse Determinations (Denials)
To ensure timely response to an appeal, please include the following information and submit to:
Majoris Health Systems
Medical Director
PO Box 1728
Lake Oswego, OR 97035
The following information should be included in the appeal:
- Your full name,
- Your social security number,
- If appealing party is not the enrollee, include the full name and relationship to the enrollee,
- Dates of service during which appeal took place, if applicable,
- Place where service(s) took place, i.e., hospital, doctor’s office, radiology, home health visit at home, etc. if applicable,
- If appeal is for Emergency Room services, please send copy of the Emergency Room record,
- Provide a brief description of the incident, including names, dates and times that will support resolution of the appeal.
Complaints to Texas Department of Insurance
Anyone may submit a complaint to the Texas Department of Insurance. Send complaint to:
Texas Department of Insurance
HMO Division, Mail Code 103-6A
P.O. Box 149104
Austin, TX 78714-9104
Toll Free: 1-800-252-7031
Or Fax the complaint to: (512) 490-1012
You may use the online complaint form at www.tdi.state.gov/forms.
Send email complaints to: [email protected] or [email protected].