Montana: Dispute Procedures

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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 the dispute. Failure to appeal in a timely manner means the provider waives their right to appeal. 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 Montana, Inc.
P.O. Box 1728
Lake Oswego, OR 97035

Administrative Disputes

Disputes or complaints about administrative issues or concerns should be directed in writing to the Majoris Administrator at the address listed above and received by Majoris within 30 days of the date of the action giving rise to the dispute.

Medical Disputes

When a medical dispute arises, it is reviewed by the Majoris Medical Director. The Medical Director may uphold or reverse the original decision. This decision will be made within 15 days of Majoris’ receipt of the dispute. If the original decision is overturned, all parties are notified and the dispute process is completed. If the original decision is upheld, all parties are notified and the Medical Director refers the dispute 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 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 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.

Use the Claim Rep Lookup link to get the contact info for the Majoris™ claim representative assigned to a specific claim.

Find a Claim Rep

Majoris offers a unique medical review process that ensures high-quality care from enrollment to resolution. We proactively monitor key events, maintain regular communication with claims adjusters and managers, and leverage our physician reviewers to handle complex cases. Our approach includes:

  • Proactive File Review Medical Management
  • Medical Treatment Reviews by Board-Certified Physicians
  • Evidence-Based, Peer-Reviewed Guidelines
  • Physician-to-Physician Treatment Collaboration

Additionally, we address common concerns within the workers’ compensation system with innovative programs like our prospective opioid management and sprain/strain programs. This ensures treatment plans and physical restrictions are informed by objective findings, are focused on the work injury, and incorporate a progressive return to work and life activities. The result is higher quality care and significant long-term savings.

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Better networks create better results.

Majoris is selective in the providers we partner with, seeking those who understand the unique demands of treating workers’ compensation patients and who meet high credentialing standards. Our provider relations staff keeps in close contact with our providers to support strong relationships, providing training on workers’ compensation best practices and outreach on individual cases experiencing administrative stall-outs.

When there are questions about treatment, providers can expect to speak with a board-certified physician with a background in treating injured workers. Our outreach is centered on collaboration, with the goal of finding the right treatment plan for each patient’s unique needs.

Credentialing

Credentialing goes beyond confirmation of licensure and malpractice history – we look at past treatment records to ensure there is evidence of sound medical reasoning, reliance on objective medical findings and integration of daily activities and work into the overall rehabilitation plan.

Best Practice Standards

To support their responsibilities as a provider of care to injured workers, Majoris developed a series of guidelines, protocols and techniques to facilitate efficient delivery of care within the workers’ compensation framework. This includes support of other stakeholders’ responsibilities.

Our provider manual offers a road map of best practice, streamlining the flow of required information to reduce effort and administrative burden for all. Our treatment guidelines are derived from evidence-based medicine and specific to the workers’ compensation patient population when the data is available.

All network providers have committed to following these best practices, and our provider relations team provides hands-on support when needed to ensure information is received and timelines are met.

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We utilize sophisticated IT solutions, featuring customized programs and advanced data interfaces. The result is seamless collaboration with all stakeholders and high data integrity. Our cutting-edge technology streamlines operations, enhances communication, and drives effective collaboration.

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