Texas: Complaint & Appeal Procedures

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For general complaints, disputes or appeals, a party should contact Majoris Health Systems by letter, email or phone. All complaints and disputes must be submitted within 90 days of the date of the disputed action.

The complaint should be mailed to:

Majoris Health System

Employee Complaint Department

PO Box 1728

Lake Oswego, OR 97035

877-304-9526

Email: [email protected]

Your complaint should include a brief description of the incident, including names, dates and times that will support resolution of the complaint.

Majoris Health Systems will send a letter within seven days to confirm we received your complaint. The letter will explain the complaint process, time frames and will include a one-page complaint form for you to complete if the complaint is received verbally. We may also ask for any additional information warranted to process the complaint. If you have questions, Majoris is always available to discuss them with you.

After investigating a complaint, Majoris will send a resolution letter no later than 30 calendar days of receiving the written or verbal complaint.

If you are not satisfied with how your complaint was resolved or handled, you can file a complaint with the Texas Department of Insurance.

Majoris Health Systems will not retaliate against anyone—whether an employee, employer, or provider—because they or someone acting on their behalf has filed a complaint against the network.

Adverse Determinations Utilization Review (Denials)

Adverse determination means that Majoris Health Systems’ review has decided the medical services provided or planned are not medically necessary or appropriate.

If you want to appeal a decision made during the service review or quality assurance process, you must do so either verbally or in writing. The appeal or complaint may be made by the patient, someone acting on the patient’s behalf, or by the patient’s physician or health care provider.

To ensure timely response to an appeal, please include the following information and submit to:

Majoris Health Systems

Medical Director

PO Box 1728

Lake Oswego, OR 97035

Or

Email: [email protected]

The following information should be included in the appeal:

  • Your full name and birthdate.
  • If appealing party is not the enrollee, include the full name and relationship to the enrollee,
  • Dates of service being appealed, if applicable,
  • Place where service(s) took place, i.e., hospital, doctor’s office, radiology, home health visit at home, etc. if applicable,
  • If appeal is for Emergency Room services, please send copy of the Emergency Room record,
  • Provide a brief description, including names, dates and times that will support resolution of the appeal.
  • Explain in your appeal why you believe the decision is wrong.

When a medical dispute arises, the Majoris Medical Director refers it to a member of the Medical Review Committee (MRC). This committee consists of physicians with the necessary expertise, and it does not include the doctor who made the original decision.

The committee member will review the issue and decide whether to uphold the decision, gather more information, or reverse the decision. Any additional medical information required will be included in the review. If a patient evaluation is necessary, the injured worker must participate for the reconsideration process to be completed.

The reconsideration process will be completed within 30 days of receiving the request. After the process is finished, Majoris will notify all parties in writing of the decision, providing an explanation, the medical reasons for the decision, the credentials of the consulted medical providers, and their state(s) of licensure.

Parties will also be informed of their right to seek review of a denial by an Independent Review Organization. Forms for requesting this review are included with the notice and are available on the Texas Department of Insurance website (www.tdi.state.tx.us) or by sending a written request to:

HMO Division

Mail Code 103-6A

Texas Department of Insurance

P.O. Box 149104

Austin, TX 78714-9104

If requesting an Independent Review, the request must be made within 45 days after the denial of reconsideration.

If you have questions or need help completing the form, you can contact Majoris Health Systems at the number below or the Texas Department of Insurance at the number provided on the form.

Majoris will promptly inform the Texas Department of Insurance (TDI) when an Independent Review is requested. This notice will be sent electronically using the form required by TDI.

The Utilization Review Agent can contact TDI for an Independent Review Organization assignment between 7:00 a.m. and 5:00 p.m. CST, Monday through Friday. TDI will then notify Majoris and the patient of the assigned Independent Review Organization.

Within three days of this notification, Majoris must provide the following to the Independent Review Organization:

  • All relevant medical records relating to the issue in dispute
  • Any documents relied upon for the Utilization Review decision by Majoris
  • A copy of the notification of the results of the Internal Review by Majoris
  • Any information provided to Majoris to support the appeal
  • A list of names and phone numbers of any healthcare provider who has provided treatment and/or may have records relevant to the appeal

Majoris will be bound by the decision of the Independent Review Organization regarding medical necessity. Majoris will pay for the Independent Review, but may charge the fee back to the payor, depending on the individual carrier contract.

Special Appeal Rights

Parties will be entitled to expedited reconsideration procedures for denials of preauthorization of treatment involving post-stabilization treatment, life threatening conditions, or denials of continued stays for hospitalized employees. Such requests will be reviewed in the same manner as listed above, but a response will be provided within one working day from the date of receipt of all information necessary to complete the reconsideration.

A patient with a life-threatening condition is not required to complete the reconsideration process but may proceed directly to a request for independent review. The enrollee, person acting on behalf of the enrollee, or the enrollee’s provider of record shall determine the existence of a life-threatening condition on the basis that a prudent layperson possessing an average knowledge of medicine and health would believe that their disease or condition is a life-threatening condition.

If you believe you qualify and want to request review by an Independent Review Organization, you may do so at no cost to you. The Texas Department of Insurance will randomly assign an Independent Review Organization to your case and will notify us within one day of that assignment. We will then provide all of the necessary medical records for your case to the Independent Review Organization for their review.

Complaints to Texas Department of Insurance

Anyone may submit a complaint to the Texas Department of Insurance. Send complaint to:

Texas Department of Insurance, Division of Workers’ Compensation

Compliance and Investigations, Mail Code C1

P.O. Box 12050

Austin, TX 78711

Email: [email protected]

Or Fax the complaint to: (512) 489-1030

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

You may use the online complaint form at:

English Form
Spanish Form

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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