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 educated 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 your doctor and insurer to help you return to gainful employment as soon as possible after an on-the-job injury or illness.

No. Majoris contracts with workers’ compensation insurance companies and self-insured employers to provide managed care services for injured workers. We help ensure medical care is appropriate, necessary, and aligned with 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 adjuster.

In most cases, yes. Once your workers’ compensation claim is enrolled you are required to treat with an MCO provider unless one of the circumstances below applies. If you are enrolled in the MCO before your claim is accepted, your workers’ compensation insurer will pay for reasonable and necessary care from an MCO network provider, even if the claim is later denied, unless your health insurance covers it. This requirement applies until you receive notice of the denial, or until three days after the denial is mailed, whichever occurs first.

Below are the situations in which you may receive care from a non-network provider after your workers’ compensation claim is enrolled:

1. You have a primary care physician who qualifies as outlined below.

Your attending physician may be approved to treat you under the managed care arrangement, even if they are not on the Majoris list of contracted providers. To qualify:

• Your provider must be a medical doctor (MD), osteopath (DO), chiropractic physician (DC), nurse practitioner (NP), or physician associate (PA).
• Your provider must be a family practitioner, general practitioner, internal medicine specialist, chiropractor, nurse practitioner or physician associate.
• You must have a history of being treated by that provider prior to your injury date or have them as a designated primary care provider under your group health plan.
• The provider must agree to abide by all terms and conditions of Majoris Health Systems, and must refer you to a Majoris provider for any additional care you may need they cannot provide.

2.  There are fewer than three MCO providers available in a given category in Majoris’ geographical service area.

You may be allowed to seek treatment from a non- Majoris provider if there are fewer than three Majoris providers in the following categories:

*Acupuncturist (L.A.C.)

*Optometrist (O.D.)

*Chiropractor (D.C.)

*Dentist (D.M.D. or D.D.S.)

*Naturopath (N.D.)

*Osteopath (D.O.)

*Physician (M.D.)

*Podiatrist (D.P.M.)

*Physical therapist (PT)

*Psychologist

*Nurse Practitioner (NP)

*Physician Assistant (PA)

All non-network treatment remains subject to Majoris’ utilization and treatment standards.

3. You reside outside Majoris’ geographical service area.

If you reside outside Majoris’ geographical service area (state of Oregon) you may select a non-network provider if they practice closer to your residence than an MCO provider of the same category and if they agree to the terms and conditions of the MCO.

If you think you qualify for any of the above exceptions and would like consideration for non-network treatment, please contact your Majoris claim representative.

Should you receive care from a provider who does not meet the above criteria for non-network treatment, your workers’ compensation insurer will not be required to pay for medical services. In addition, the provider will not be allowed to authorize your time loss from work.

If you live more than one hundred miles from Majoris’ geographic service area (the state of Oregon), your claim will not be eligible for enrollment.

In most cases, you will need to transfer to an MCO network provider, unless one of the exceptions above applies.

If Majoris determines that changing providers would be medically detrimental for your recovery, you may continue your treatment until you become medically stationary or choose to change providers, whichever occurs first.

If you are not medically stationary and believe that a change of providers would be medically detrimental to you, you may send a request to Majoris and ask for review. Such a request must be made in writing.

If you would like help scheduling an appointment, or if you have contacted several network providers and were unable to schedule a timely appointment, please contact your Majoris claim representative for assistance.

In emergency situations, Majoris, your employer, and your insurer agree that your immediate safety and care come first. An emergency is a medical condition where a delay in treatment could lead to death, serious disability, or other significant health consequences.

If you cannot access a Majoris network provider in an emergency, seek care at the nearest appropriate medical facility. After you are out of immediate danger, all follow-up care must be provided within the MCO network.

Emergency care should not be used as a substitute for routine, ongoing medical care from an attending physician.

Majoris is not involved in care that is not work-related, including conditions your workers’ compensation insurer has denied.

Use your health insurance for care and contact your Employee Benefits department or private insurance carrier with any questions.

Majoris is here to make sure you receive timely, effective, and quality medical services for your work-related injury. If you disagree with decisions made by Majoris or with care provided by your network providers, you may request review through Majoris’ Dispute Resolution Process.

Requests must be made in writing within 30 days of the decision you disagree with. You should state the specific issue and include any information you think we should consider in our review. Requests can be mailed to Administrator, Majoris Health Systems, P.O. Box 1728, Lake Oswego, OR 97035, faxed to 503-601-8437, or emailed to your Majoris claim representative.

When you submit your request timely, we will review the disputed decision and notify you of our decision within 60 days. If you continue to disagree with our decision, you may then appeal to the Director of the Department of Consumer and Business Services for further review.