Second Opinion by a Physician
- 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.
Members who initiate a request for a second or third opinion are limited to in-network providers, except where appropriate in-network providers are not accessible.
If the member refuses to see an in-network provider and is requesting an out-of-network provider, all requests for a second opinionfrom a non-participating provider, should be directed to the Health Net Member Services Department or the CalViva Health Medi-Cal Member Services Department.
The health plan and delegated participating physician groups (PPGs) provide timely referral for a second opinion consultation by an appropriately qualified health care professional when the second opinion is requested by a member or the member's physician. An appropriately qualified health care professional is a primary care physician (PCP) or specialist acting within the PCP's or specialist's scope of practice and possessing clinical background, training and expertise related to the particular illness, disease or other condition associated with the request for a second opinion. Second opinion referrals are approved for a one-time-only consultation. All tests, lab and X-ray services must be directed back to the member's PPG or PCP for coordination. All care must be performed or authorized by the PPG or PCP in order to be covered. There are few, if any, circumstances under which second opinion requests should be denied.
PPGs delegated for utilization management (UM):
- Provide second opinions by an appropriately qualified health care professional (of the same or equivalent specialty) of the member's choice, from the PPG's network
- Make every effort to accommodate the member within the PPG network
- Must consider all participating specialists for second opinion referrals
- Should instruct members who request an out-of-network second opinion and refuse to accept redirection in-network, to contact the Health Net Member Services Department or the CalViva Health Medi-Cal Member Services Department for further assistance
- Authorizes second opinions from appropriately qualified health care professional (of the same or equivalent specialty) of the member's choice from the plan's network when appropriate
- May limit referrals to its network providers if criteria for appropriately qualified health care professionals are met within the network. The health plan authorizes a second opinion by an appropriately qualified out-of-network health care professional when no participating health plan provider is available