APPEAL PROCEDURES
(Workers' Comp Network UR)
Appeals arising from decisions made in the service utilization review process or quality assurance process must be made orally, or in writing. Any complaints arising from services provided by Majoris may be made at any time. The appeal or complaint may be made by the patient or someone acting on their behalf, or by the patient's physician or health care provider. 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, Inc.
P.O. Box 3810
Tualatin, OR 97062-3810
1-800-525-0394
Disputes or complaints about administrative issues or concerns should be directed in writing to the Majoris Administrator at the address listed above within 15 days of the date of the action giving rise to the dispute or complaint. Administrative issues or concerns will be reviewed by the Majoris Administrative Review Committee.
Majoris will notify all parties in writing within five days of the receipt of a request for appeal. At that time, a request will be made for any additional information or documents that the requesting party must submit in order to complete the review. Absent a showing of good cause, failure to reconsideration within 15 days of the action giving rise to the dispute shall preclude further reconsideration by an Independent Review Organization or Texas Department of Insurance.
When a medical dispute arises, it is referred by the Majoris Medical Director to a member of 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, and will not include the physician who made the original decision. The Committee member 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 reconsideration process, it will be included in the review. If the MRC determines an actual patient evaluation is required to determine the outcome of the dispute, successful completion of the reconsideration 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 made by the HCN will be upheld.
Mail Code 103-6A
Texas Department of Insurance
PO Box 149104
Austin, TX 78714-9104
Any request for independent review must be filed not later than the 45th day after the reconsideration process is completed by Majoris.
If you have any questions or need assistance in completing this form, you may contact Majoris Health Systems at the number below, or contact the Texas Department of Insurance at the number provided on the form.
Majoris will promptly notify the Texas Department of Insurance when there has been a request for independent review. Notice will be made via electronic transmission, and will be on the form required by TDI. The utilization review agent may access the department on working days, between 7:00 a.m. and 6:00 p.m. Central time, Monday through Friday, to obtain assignment of an independent review organization.
The Department will then advise Majoris and the patient of the IRO assigned. Within three days of that notification, Majoris must provide to the IRO:
- All relevant medical records relating to the issue in dispute
- Any documents relied upon for the UR decision by Majoris
- A copy of the notification of the results of the internal review by Majoris
- Any information provided to Majoris submitted to support the appeal
- A list of names and phone numbers of any health care provider who has provided treatment and/or may have records relevant to the appeal.
Majoris will be bound by the decision of the IRO 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 his or her 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 Department of Insurance will randomly assign an independent review organization (IRO) 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 IRO for their review.
The necessary form to request such review is included with this notice. If you have any questions or need assistance in completing this form, you may contact Majoris Health Systems at the number below, or contact the Texas Department of Insurance at the number provided on the form.
DISAPPROVALS BASED ON EXTENT OF INJURY
If the requested medical services have been denied due to the extent of injury under Labor Code å¤408.0042, any party may request a Benefit Review Conference. The patient may make a request for a Benefit Review Conference in any form, but all other parties must use DWC form 45, available on the TDI website.