Your employer or Workers’ Compensation insurer has contracted with Majoris Health Systems Montana, Inc.(Majoris) to provide the services of a managed care organization (MCO) to employees injured on the job.
We understand that dealing with an injury can sometimes be stressful and confusing. We therefore recommend that you become familiar with the Majoris procedures before you may need to seek care for a work-related injury or illness.
Following are answers to some of the more commonly asked questions concerning our managed care program. Should you have additional questions, please feel free to contact your workers’ compensation insurance representative, or you may contact Majoris Health Systems directly at 800-525-0394.
What is Majoris Health Systems Montana?
Majoris is a state-certified managed care organization (MCO). We contract with physicians, hospitals, and other health care providers to provide medical services to covered employees with work-related injuries or illnesses. Our providers are carefully selected and trained in the treatment of work-related conditions. Majoris, and its health care providers, wants to make sure that timely, effective, and convenient medical services are available for our covered workers. Majoris will also be working closely with your doctor and employer to help you return to gainful employment as soon as possible after an on-the-job injury or illness.
Is Majoris a Workers’ Compensation insurance company?
No. Majoris contracts with insurance companies and self-insured employers to provide medical treatment to injured workers. We also monitor medical care that is given to ensure that it is appropriate and necessary, and that it meets our high quality standards.
Majoris does not make decisions on acceptance or denial of claims, payment of time loss or medical benefits, or any other workers’ compensation benefits. Decisions concerning these and all other claims issues remain the responsibility of the claims examiner for the insurer or self-insured employer.
When will my claim be “enrolled”?
Your claim will be enrolled in the MCO when one of the following occurs:
a) Your injury results in total loss of wages for any duration;
b) Your injury will result in permanent impairment;
c) Your injury results in the need for a referral to another medical provider for specialized evaluation or treatment; or
d) Specialized diagnostic tests are required.
Am I required to see one of the Majoris doctors if I am injured on the job and need medical care?
In most cases, yes. However, there are two circumstances in which you may receive treatment from a non-Majoris provider. They are:
1. Prior to claim enrollment
You may receive treatment from a non-Majoris physician prior to your claim being enrolled in the MCO. However, once your work-related claim is enrolled, you are required to seek care from an Majoris authorized attending physician. If your physician does not meet Majoris requirements, you will be required to change physicians at the time your claim is enrolled. So, you may want to use an Majoris provider before your claim is accepted, to avoid interruption in your medical care. Once your claim is enrolled, you may receive care from a non-Majoris physician only in the following situation:
2. . You have a private physician who qualifies as a primary care physician.
Your family physician may qualify to treat you under the managed care arrangement, even if he or she is not on the Majoris list of contracted providers. To qualify:
•Your doctor must be a medical doctor (M.D.), an osteopath (D.O.), or a chiropractor (D.C.), and
•Your doctor must be a family practitioner, general practitioner, or internal medicine specialist,
•You must have a history of being treated by that doctor, or have the doctor as a designated primary care provider under your group plan,
•The doctor must agree to abide by all terms and conditions of Montana Health Systems, and must refer you to an Majoris provider for any specialized care you may need.
Should you receive care from a provider who does not meet the above criteria for out-of-panel treatment, your Workers’ Compensation insurer or self-insured employer will not be required to pay for medical services. In addition, the provider will not be allowed to authorize your time loss from work.
A list of Majoris providers will be disbursed to you at the time you have a work-related injury or illness that is subject to the MCO agreement. You may also obtain a list of providers by contacting Majoris or by visiting the “Find a Provider” tab on this website.
A list of Majoris providers in your geographical service area will be provided to you at the time you have a work-related injury or illness that is subject to the MCO agreement. You may also obtain a complete panel list for the entire state by contacting Majoris. back to top
What do I do if there is a medical emergency and I’m not able to see an Majoris provider?
If you live more than one hundred miles from MHS’s geographic service area, you will not be subject to the MCO arrangement.
What if I am currently receiving care from a non-MCO provider for a work-related injury or illness at the time I am enrolled into the MCO program?
In true emergency cases which create the risk of death, serious disability, or serious medical consequences, Majoris, your employer, and insurer believe the first priority is to have the medical emergency taken care of and the worker removed from immediate danger. If you are far away from or otherwise unable to receive care from an Majoris provider in an emergency facility, seek care from the nearest appropriate medical facility. All follow-up care will be provided within the MCO. If emergency care is needed and an appropriate Majoris facility is available, seek care there.
If you are in need of emergency care and unsure of where to go, seek medical care from the closest available medical facility.
What about medical care I might need for non-work related conditions?
Majoris has no involvement with medical care that you might seek for illness or injuries that are not job related. You will continue to receive group health benefits, if any, as provided by your employer. Contact your Human Resources or Employee Benefits department for information concerning these benefits.
What do I do if I am injured on the job?
Report all injuries to your designated employer representative immediately. He or she will provide you with necessary forms to complete.
Once your claim is enrolled by the insurer, if you require medical care, you may choose to see any physician in the Majoris Provider Directory who is listed as a “Treating Physician.” Or, you may treat with a non-Majoris physician as explained previously. You may not go directly to a specialist for treatment without referral from an Majoris-approved attending physician, unless specifically approved by Majoris in advance.
If you have trouble scheduling an appointment, Majoris will be happy to assist you.
In addition, you should always follow all of your company’s rules relating to a work-related injury, including reporting requirements, modified work schedules, etc.
What can I do if I disagree with an action taken by Majoris or its member physicians?
All disputes or requests for review regarding actions taken by Majoris must first be reviewed through the Majoris internal dispute resolution process, as follows:
Any injured worker, medical provider, or employer/insurer having a dispute or request for review arising from the actions of Majoris or its representatives may direct such issues to the Majoris Administrator. All such requests must be made in writing, and must be made within 30 days of the action giving rise to the complaint. All requests should include an explanation of the issue or decision being disputed, and should include all additional medical evidence the requesting party believes should be included in Majoris’ review.
All disputes will be reviewed and responded to within 15 days of receipt of all information necessary to issue a decision.
If a dispute cannot be satisfactorily resolved through Majoris’ internal dispute resolution process, the party requesting review may appeal to the Montana Department of Labor and Industries.