DISPUTE RESOLUTION PROCEDURES
Dispute resolution includes the resolution of disputes arising under peer review, service utilization review, and quality assurance activities between insurers, self-insured employers, injured workers, and medical and health care service providers, as required under the certified plan (ORS 656.260(4)(d)(D)).
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 thedispute. 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, 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 within 30 days of the date of the action giving rise to the dispute. Administrative issues or concerns will be reviewed by the Majoris Administrative Review Committee.
Majoris will notify all parties in writing when a dispute is received. Absent a showing of good cause, failure to appeal within 30 days of the action giving rise to the dispute shall preclude further appeal to the Director of the Department of Consumer and Business Services.
When a medical dispute arises, it is referred by the Majoris Medical Director 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 Medical Director and/or 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 made by the MCO 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, as well as the right to seek administrative review by the Director of the Department of Consumer and Business Services.