FAQ for Insurers
Q: What is Majoris Health Systems?
A: Majoris is a state-certified certified workers’ compensation health care network. 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 for their expertise 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 injured workers’ doctors and insurer to help them return to gainful employment as soon as possible after an on-the-job injury or illness.
Q: Is Majoris a Workers’ Compensation insurance company?
A: No. Majoris contracts with insurance companies and self-insured employers to provide managed care services to injured workers. We monitor medical care that is provided to ensure that it is appropriate and necessary, and that it meets our 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.
Q: Is the injured worker required to see one of the Majoris doctors if they are injured on the job and need medical care?
A: In most cases, yes. The injured worker will be required to treat with an HCN provider unless one of the circumstances explained below applies:
1: The injured worker selects their current health maintenance organization (HMO) primary care physician as the treating doctor for the workers’ compensation claim. In order for the HMO doctor to be approved as the treating doctor, s/he must agree to the terms of the network contract, and agree to abide by applicable laws and regulations. If the HMO doctor is not approved, then the injured worker must see a network treating doctor.
2: Emergency care if needed. If the injured worker is hurt at work and it is a life threatening emergency, they should go to the nearest emergency room. After the injured worker receives emergency care, they may need ongoing care. The injured worker will need to select a treating doctor from the network’s provider list.
3: The injured worker does not live within the Majoris service area.
4: The injured worker’s treating doctor refers them to an out of network provider or facility. This referral must be approved by Majoris.
If the injured worker believes they qualify for any of the above exceptions and would like consideration for treatment, please contact Majoris Health Systems.
Should the injured worker receive care from a provider who does not meet the above criteria, the Workers’ Compensation insurer will not be required to pay for medical services.
Q: What kind of doctor qualifies as a treating physician?
A: Any family practice, general practice, internal medicine, or occupational medicine physician listed on the Majoris Provider List qualifies as a treating physician.
Q: How many days does the injured worker have to select a treating doctor?
A: The injured worker has 14 days from the date they receive written notification of the network requirements from their employer to select a treating doctor. If the injured worker fails to select a treating doctor within this timeframe, Majoris may assign one for them.
Q: What if the injured worker is not satisfied with their initial choice of treating doctor?
A: If the injured worker is dissatisfied with their initial choice of treating doctor they may elect an alternate doctor from the list of network treating doctors in the service area where they live. Any subsequent changes of treating doctor must be approved by Majoris Health Systems.
Q: What if the injured worker lives a long distance from the Majoris service area?
A: If the injured worker believes they live outside of Majoris’s service area (more than 30 miles in a non-rural area or more than 60 miles in a rural area) they may request a service area review by calling Majoris Health Systems. The injured worker may be required to provide proof that they live outside of the service area. They can expect to receive a response to their request within 7 days.
Q: What if the injured worker is currently receiving care from a non network provider for a work-related injury or illness at the time they are enrolled into the HCN program?
A: The injured worker may be required to treat with an HCN provider; however, they will receive a specific notice of the requirement to change physicians, and continuity of care will be considered.
Q: What should the injured worker do if there is a medical emergency and they are not able to see a Majoris provider?
A: 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 HCN, and the injured worker is far away from or otherwise unable to receive care from a Majoris provider, in an emergency they should seek care from the nearest appropriate medical facility. After the injured worker is out of immediate danger, all follow-up care will be provided within the HCN. 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, they should seek medical care from the closest available medical facility. Emergency care should not be used as a substitute for routine, ongoing medical care from the treating doctor.
Q: What about medical care the injured worker might need for non-work related conditions?
A: Majoris has no involvement with medical care that the injured worker might seek 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.
Q: What does the worker do if they are injured on the job?
A: Report all injuries to a designated employer representative immediately. S/he will provide the injured worker with necessary forms to complete.
Once the claim is enrolled in the HCN and the injured worker has received notification of the network requirements, if they require medical care, they may choose to see any physician on the Majoris Provider list who is listed as a ‘Treating Doctor’. If the injured worker has trouble scheduling an appointment or needs help in accessing care, Majoris will be happy to assist them.
In addition, the injured worker should always follow their company’s rules relating to work-related injuries including reporting requirements, modified work schedules, etc.
Q: What can the injured worker do if they disagree with an action taken by Majoris or its member physicians?
A: Majoris wants to make sure the injured worker receives timely, effective and convenient medical services for their work-related injury. However, should a dispute arise concerning care within the HCN, the injured worker may request review through Majoris Internal Dispute Resolution Process.