MAJORIS HEALTH SYSTEMS MONTANA DISPUTE RESOLUTION PROCEDURES
Disputes or complaints arising from decisions made in the service utilization review process or quality assurance process must be made in writing within thirty (30) days of the action giving rise to the dispute. Failure to appeal in a timely manner means the provider waives their right to appeal. The dispute or complaint should include any additional information the party wishes to have considered in the review by Majoris and be directed to:
Majoris Health Systems Montana, Inc.
P.O. Box 1728
Lake Oswego, OR 97035
Disputes or complaints about administrative issues or concerns should be directed in writing to the Majoris Administrator at the address listed above and received by Majoris within 30 days of the date of the action giving rise to the dispute.
When a medical dispute arises, it is reviewed by the Majoris Medical Director. The Medical Director may uphold or reverse the original decision. This decision will be made within 15 days of Majoris’ receipt of the dispute. If the original decision is overturned, all parties are notified and the dispute process is completed. If the original decision is upheld, all parties are notified and the Medical Director refers the dispute to 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. The Committee will review the medical treatment issue and make a determination whether to uphold the decision, obtain additional information, or reverse the decision. Any time additional medical information is required or obtained through the dispute resolution process, it will be reviewed by the Majoris Medical Director and/or the MRC and either the dispute will be resolved or will move through the process as described above. If the MRC determines an actual patient evaluation is required to determine the outcome of the dispute, successful completion of the dispute resolution process is predicated on the injured worker participating in the suggested evaluation. If the injured worker refuses to participate in an evaluation recommended by the MRC to make a determination in the dispute, the initial decision will be upheld.
The dispute resolution process will be completed within 60 days of the date that Majoris receives written notice of a dispute. At the completion of the dispute resolution process, Majoris will notify all parties of the decision in writing. Such notice will include an explanation of the reasons for the decision.