FAQ for Insurers
The employer or Workers’ Compensation insurer has contracted with Majoris Health Systems, Inc. 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 become familiar with the Majoris procedures before they 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 there be additional questions, please feel free to contact the workers’ compensation insurance representative, or Majoris Health Systems directly at (503) 639-6080, or (800) 525-0394.
What is Majoris Health Systems?
Majoris is a state-certified managed care organization. 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 the health care providers in our network, want to make sure that timely, effective, and convenient medical services are available for our covered workers. Majoris will also be working closely with the doctors and insurer to help the injured worker 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.
Is the 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. Once the claim is “enrolled” by the workers’ compensation insurance carrier (which means the injured worker has been have been given written notice of their requirement to treat within the MCO) the injured worker will be required to treat with an MCO provider unless one of the circumstances explained below applies. However, if the injured worker is enrolled in the MCO prior to the claim being accepted, the workers’ compensation insurance company will be required to pay for all reasonable and necessary medical services related to the claim received from an MCO member provider that are not otherwise covered by the worker’s group health insurance. This requirement applies even if the claim is denied, until the worker receives notice of the denial, or until three days after the denial is mailed, whichever occurs first.
The situations in which the injured worker may receive compensable care from a non- Majoris provider after their claim is enrolled follow.
1. The injured worker has a private physician or nurse practitioner who qualifies as a primary care physician or authorized nurse practitioner.
The injured worker’s physician or authorized nurse practitioner may qualify to treat them under the managed care arrangement, even if he or she is not on the Majoris list of contracted providers. To qualify:
- Your provider must be a medical doctor (M.D.) or osteopath (D.O.), chiropractic physician (D.C.) or authorized nurse practitioner.
- Your doctor must be a family practitioner, general practitioner, internal medicine specialist, chiropractor, or authorized nurse practitioner.
- The injured worker must have a history of being treated by that doctor or authorized nurse practitioner, or have the doctor or authorized nurse practitioner as a designated primary care provider under their group health plan.
- The doctor or authorized nurse practitioner 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 additional care that may be needed.
If your authorized nurse practitioner is qualified to provide your care, he or she will be allowed to provide medical treatment and authorize time loss for 180 days from the date of the first nurse practitioner visit on the initial claim.
2. There are fewer than three MCO providers available in a given category in Majoris’ geographical service area.
The injured worker may be allowed to seek treatment from a non- Majoris provider if there are fewer than three Majoris providers in the following categories:
*Dentist (D.M.D. or D.D.S.)
*Authorized nurse practitioner
All out-of-panel treatment will be subject to Majoris’ utilization and treatment standards.
3. The injured worker resides outside Majoris’ geographical service area.
If the injured worker resides outside Majoris’ geographical service area they may select a non-MCO provider if they practice closer to the injured worker’s residence than an MCO provider of the same category and if the provider agrees to the terms and conditions of the MCO.
If the injured worker thinks they qualify for any of the above exceptions and would like consideration for out-of-panel treatment, they should contact Majoris Health Systems.
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 will not be required to pay for medical services. In addition, the provider will not be allowed to authorize time loss from work.
A list of Majoris providers in the worker’s geographical service area will be provided to them at the time they have a work-related injury or illness that is subject to the MCO agreement. The worker may also obtain a complete panel list for the entire state by contacting Majoris.
What if the injured worker lives a long distance from Majoris’ service area?
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?
The injured worker will be required to treat with an MCO provider, with the exceptions noted above. However, if the injured worker has not yet been declared medically stationary, are required to change physicians, and the MCO determines that it would be medically detrimental for them to change physicians, they would not be subject to the MCO requirements until they become medically stationary or choose to change physicians, whichever occurs first.
If the injured worker is not yet medically stationary and think that a change of physicians would be medically detrimental to, they may request review of their situation by the MCO. To request review, please submit a request in writing to the address listed within 30 days of the date of the action. Failure to request review in writing within 30 days precludes further appeal.
What if the injured worker needs help finding or scheduling an appointment with an MCO provider?
If the injured worker would like help in scheduling an appointment, or if they have contacted several panel providers and were not able to schedule a timely appointment, they can contact Majoris for assistance.
What should the injured worker do if there is a medical emergency and they are not able to see an Majoris provider?
In true emergency cases, 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. An emergency is defined as a medical condition that if treatment is not rendered immediately, creates the risk of death, serious disability or serious medical consequences.
If the claim is subject to the MCO, and the injured worker is far away from or otherwise unable to receive care from a Majoris provider in an emergency, the injured worker should seek care from the nearest appropriate medical facility. After the worker is out of immediate danger, all follow-up care will be provided within the MCO. If emergency care is needed and an appropriate Majoris facility is available, care should be sought from the Majoris member facility if possible.
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. Emergency care should not be used as a substitute for routine, ongoing medical care from an attending physician.
What about medical care the injured worker might need for non-work related conditions?
Majoris has no involvement with medical care that may be needed for illnesses 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 should the injured worker do if injured on the job?
All injuries should be reported to a designated employer representative immediately. He or she will provide the injured worker with necessary forms to complete.
Once the claim is enrolled in the MCO, if the injured worker requires medical care, they may choose to see any physician on the Majoris Provider list who is listed as an “Attending Physician”, or an Authorized Nurse Practitioner listed under Non-Attending Physicians. Authorized Nurse Practitioners will be allowed to provide medical treatment and authorize time loss for 180 days from the date of the first nurse practitioner visit on the initial claim. Or, the injured worker may treat with a non- Majoris provider as explained previously.
If the injured worker has trouble scheduling an appointment or needs help in accessing care, Majoris will be happy to assist them.
In addition, injured workers should always follow their company’s rules relating to work-related injuries including reporting requirements, modified work schedules, etc.
What can be done if the injured worker disagrees with an action taken by Majoris or its member physicians?
Majoris wants to make sure injured workers receive timely, effective and convenient medical services for their work-related injuries. However, should a dispute arise concerning the care within the MCO, injured workers may request review through Majoris’ Internal Dispute Resolution Process.
Such request must be made in writing within 30 days of the action giving rise to the dispute. The injured worker should state the specific issue for which they are requesting review, and include any information they think we should consider in our review. Address requests to Administrator, Majoris Health Systems, P.O. Box 1728, Lake Oswego, OR 97035. If the appeal is received timely, we will review the disputed decision and notify all parties of our decision within 60 days of the request. Thereafter, if the injured worker continues to disagree with our decision, they may appeal to the Director of the Department of Consumer and Business Services for further review.
Please note that failure to request a review in writing to Majoris Health Systems within 30 days of the action giving rise to the dispute means the injured worker loses their right of further appeal to the Director of DCBS.