Second Opinion by a Physician

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)

All requests for a second opinion meeting the California Health and Safety Code Section 1383.1 require health plans to allow members to obtain second opinions in any of the following situations:

  • Member questions the reasonableness or necessity of recommended surgical procedures
  • Member questions a diagnosis or plan of care for a condition that threatens loss of life, limb, bodily function, or substantial impairment, including a serious chronic condition
  • Clinical indications are not clear or are complex and confusing, a diagnosis is in doubt due to conflicting test results, or the treating physician is unable to diagnose the condition, and the member requests an additional diagnosis
  • Treatment plan is in progress, but is not improving the member's medical condition within an appropriate period of time given the diagnosis and plan of care
  • Member has attempted to follow the plan of care or has consulted with the initial provider with serious concerns about the diagnosis or plan of care

Second opinion consultations include a history, an examination and a medical decision of some complexity. They do not include additional tests, which have to be approved separately.

Office visits, consultations with a participating physician, or a referral to a physician or qualified professional provider necessary for obtaining a second opinion, are covered and subject to scheduled copayments.