FAQ for Insurers

An employer or Workers’ Compensation insurer has contracted with Majoris Health Systems 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 the injured worker, employer and insurance adjuster become familiar with the Majoris procedures before the need to seek care for a work-related injury or illness arises.

Following are answers to some of the more commonly asked questions concerning the Majoris managed care program. Should there be additional questions, please feel free to contact Majoris Health Systems directly at 800-525-0394.

What is Majoris Health Systems? 
 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 our covered injured workers’ doctor and employer to help them 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 can a claim be “enrolled”

A claim can be enrolled in the MCO when one of the following occurs:

a)   The injury results in total loss of wages for any duration;
b)   The injury will result in permanent impairment;
c)   The injury results in the need for a referral to another medical provider for specialized evaluation or treatment; or
d)   Specialized diagnostic tests are required.

Is the enrolled injured worker required to see one of the Majoris doctors if they are injured on the job and need medical care? 
In most cases, yes. However, there are two circumstances in which the injured worker may receive treatment from a non-Majoris provider. They are:

1. Prior to claim enrollment

The injured worker may receive treatment from a non-Majoris physician prior to the claim being enrolled in the MCO. However, once the work-related claim is enrolled, the injured worker

is required to seek care from a Majoris authorized attending physician. If the physician does not meet Majoris requirements, they will be required to change physicians at the time the claim is enrolled. So, the injured worker may want to use a Majoris provider before their claim is accepted, to avoid interruption in their medical care. Once the claim is enrolled, the injured worker may receive care from a non-Majoris physician only in the following situation:

2. The injured worker has a private physician who qualifies as a primary care physician.

The injured worker’s family physician may qualify to treat them under the managed care arrangement, even if the family physician is not on the Majoris list of contracted providers. To qualify:

•The doctor must be a medical doctor (M.D.), an osteopath (D.O.), or a chiropractor (D.C.), and
•The doctor must be a family practitioner, general practitioner, or internal medicine specialist,
•The injured worker must have a history of being treated by that doctor, or have the doctor as a designated primary care provider under their group plan,
•The doctor must agree to abide by all terms and conditions of Majoris Health Systems, and must refer the injured worker to a Majoris provider for any specialized care necessary.

Should the injured worker receive care from a provider who does not meet the above criteria for out-of-panel treatment, the 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 the injured worker’s time loss from work.

A list of Majoris providers will be disbursed to the injured worker at the time they have a work-related injury or illness that is subject to the MCO agreement. The injured worker may also obtain a list of providers by contacting Majoris or going online to www.majorishealthsystems.com.

A list of Majoris providers in the injured worker’s geographical service area will be provided to them at the time of a work-related injury or illness that is subject to the MCO agreement. The injured worker may also obtain a complete panel list for the entire state by contacting Majoris.

What if there is a medical emergency and the injured worker is not able to see a Majoris provider? 
If the injured worker lives more than one hundred miles from Majoris’ geographic service area, they will not be subject to the MCO arrangement.

What if the injured worker is currently receiving care from a non-MCO provider for a work-related injury or illness at the time they are enrolled into the MCO program? 
In true emergency cases which create the risk of death, serious disability, or serious medical consequences, Majoris, the employer, and the insurer believe the first priority is to have the medical emergency taken care of and the worker removed from immediate danger. If the injured worker is far away from, or otherwise unable to receive care from a 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 the injured worker is in need of emergency care and unsure of where to go, seek medical care from the closest available medical facility.

What about medical care the injured worker might need for non-work related conditions?

Majoris has no involvement with medical care that the injured worker might seek for illness or injuries that are not job related. The injured worker will continue to receive group health benefits, if any, as provided by their employer. The injured worker should contact their Human Resources or Employee Benefits department for information concerning these benefits.

What an injured worker do if they are injured on the job?
The injured worker should report all injuries to the designated employer representative immediately. The employer representative will provide the injured worker with necessary forms to complete.

Once the claim is enrolled by the insurer, if the injured worker requires medical care, they may choose to see any physician in the Majoris Provider Directory who is listed as a “Treating Physician.” Or, they may treat with a non-Majoris physician as explained previously. The injured worker may not go directly to a specialist for treatment without referral from a Majoris-approved attending physician, unless specifically approved by Majoris in advance.

If the injured worker has trouble scheduling an appointment, Majoris will be happy to provide assistance.

In addition, the injured worker should always follow all of their employer’s rules relating to a work-related injury, including reporting requirements, modified work schedules, etc.

What if the injured worker disagrees 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 MHS 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 MHS’s review.

All disputes will be reviewed and responded to within 60 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.