Following are answers to some of the more commonly asked questions. Should you have additional questions, please feel free to contact your workers’ compensation insurance examiner, or Majoris Health Systems at (800) 525-0394, or your Majoris claim representative directly.
What is Majoris Health Systems?
Majoris is a workers’ compensation healthcare network in the state of Texas. We contract with physicians, hospitals, and other health care providers to provide medical services to enrolled 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 enrolled workers. Majoris will be working closely with your provider(s) and insurer to help you 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 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.
Am I Required to see one of the Majoris doctors if I am injured on the job and need medical care?
In most cases, yes. You will be required to treat with an HCN provider unless one of the circumstances explained below applies:
1: You select your current health maintenance organization (HMO) primary care physician as the treating doctor for your workers’ compensation claim. In order for your HMO doctor to be approved as your treating doctor, they must agree to the terms of the network contract, and agree to abide by applicable laws and regulations. If your HMO doctor is not approved, then you must see a network treating doctor.
2: Emergency care if needed. If you are hurt at work and it is a life threatening emergency, you should go to the nearest emergency room. After you receive emergency care, you may need ongoing care. You will need to select a treating doctor from the network’s provider list.
3: You do not live within the Majoris service area.
4: Your treating doctor refers you to an out of network provider or facility. This referral must be approved by Majoris.
If you believe you qualify for any of the above exceptions and would like consideration for treatment, please contact Majoris Health Systems.
Should you receive care from a provider who does not meet the above criteria, your Workers’ Compensation insurer will not be required to pay for medical services.
What kind of doctor qualifies as a treating doctor?
Any family practice, general practice, internal medicine, or occupational medicine physician listed on the Majoris Provider List qualifies as a treating doctor.
How many days do I have to select a treating doctor?
You have 14 days from the date you receive written notification of the network requirements from your employer to select a treating doctor. If you fail to select a treating doctor within this timeframe, Majoris may assign one for you.
What if I’m not satisfied with my initial choice of treating doctor?
If you are dissatisfied with your initial choice of treating doctor you may elect an alternate doctor from the list of network treating doctors in the service area where you live. Any subsequent changes of treating doctor must be approved by Majoris Health Systems.
What if I live a long distance from the Majoris service area?
If you believe you live outside of Majoris’ service area (more than 30 miles in a non rural area or more than 60 miles in a rural area) you may request a service area review by calling Majoris Health Systems. You may be required to provide proof that you live outside of the service area. You can expect to receive a response to your request within 7 days.
What if I am currently receiving care from a non-network provider for a work-related injury or illness at the time I am enrolled into the HCN program?
You may be required to treat with an HCN provider; however, you will receive a specific notice of the requirement to change physicians, and continuity of care will be considered.
What if I need help finding or scheduling an appointment with a Majoris provider?
If you would like help in scheduling an appointment, or if you have contacted several panel providers and were not able to schedule a timely appointment, please contact Majoris for assistance.
What do I do if there is a medical emergency and I’m not able to see a Majoris provider?
In true emergency cases, Majoris, your employer, and your insurer believe the first priority is to have your medical emergency taken care of. An emergency is defined as a medical condition that creates the risk of death, serious disability, or serious medical consequences if treatment is not rendered immediately.
If your claim is subject to treating within the HCN, and you are far away from, or otherwise unable to receive care from a Majoris provider in an emergency, you should seek care from the nearest appropriate medical facility. After you are 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 you are 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 a treating doctor.
What about medical care I might need for non-work related conditions?
Majoris has no involvement with medical care that you might seek for illnesses or injuries that are not job-related. You will continue to receive group health benefits, if any, as provided by your employer. Contact your Human Resources or Employee Benefits department for information concerning these benefits.
What do I do if I am injured on the job?
Report all injuries to your designated employer representative immediately. They will provide you with necessary forms to complete.
Once your claim is enrolled in Majoris, if you require medical care, you may choose to see any physician on the Majoris Provider list who is listed as a “Treating Doctor.” Or, you may treat with a non-Majoris provider as explained previously.
If you have trouble scheduling an appointment or need help in accessing care, Majoris is happy to assist you.
In addition, you should always follow all of your company’s rules for work-related injuries including reporting requirements and modified work schedules.
What can I do if I disagree with an action taken by Majoris or one of its network providers?
Majoris wants to make sure you receive timely, effective, and convenient medical services for your work-related injury. However, should a dispute arise concerning your care within the MCO, you may request review through Majoris’ Dispute Resolution Process.
Such requests must be made in writing within 90 days of the action giving rise to the dispute. You should state the specific issue for which you are requesting review and include any information you think we should consider in our review. If you appeal timely, we will review the disputed decision and notify you of our decision within 30 days of your request. The decision will be provided to you in writing, along with instructions on how to appeal further if you continue to disagree with our decision.
Please note that failure to request a review within 90 days of the action giving rise to the dispute means you lose your right of further appeal. Disputes must be made in writing and sent to our mailing address (PO Box 1728, Lake Oswego OR 97035), faxed to 503-601-8437, or emailed to your Majoris claim representative.
