Second Opinion by a Physician
- Physicians (does not apply to Cal MediConnect)
- Participating Physician Groups (PPG)
Second opinion consultations related to member's medical need for surgery or non-surgical diagnostic or therapeutic procedures are a covered benefit. Second opinion consultations include a history, an examination and a medical decision of some complexity. Whether a second opinion request is in-network or out-of-network, an organization determination (applicable to Medicare Advantage only) must be requested. Additionally, office visits, consultations with participating physicians, or referrals to physicians or qualified professional providers necessary for obtaining a second opinion are covered and subject to scheduled copayments if applicable.
Prior authorization may be required for surgery or for a major non-surgical diagnostic or therapeutic procedure, except in an emergency. A member may contact their primary care physician (PCP) or Health Net Member Services to request authorization for a second opinion.
Additional second opinions (third opinions) are covered if the recommendation of the first and second opinion differ regarding the need for surgery or other major procedure. Additional opinions are covered even though the surgery or other procedures, if performed is determined non-covered. The surgery or other procedure request must be referred back to Health Net in order to be covered.