20-1031 Reminder: Refer Patients for a Second Opinion When Needed

Date: 12/30/20

This information applies to Physicians and Participating Physician Groups (PPGs).

This information applies to Medi-Cal in Fresno, Kings and Madera counties.

A one-time consult can help relieve patient concerns and support their plan of care

CalViva Health members can get a second opinion when any of the following occurs:

• 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 major damage, including a serious chronic condition
• Clinical signs are not clear or are complex, a diagnosis is in doubt due to conflicting test results, or the treating physician cannot diagnose the condition, and the member requests an additional diagnosis
• Treatment plan is in progress, but the medical condition is not improving in a reasonable amount of time based on the diagnosis and plan of care
• Member has attempted to follow the plan of care or has talked with the initial provider with serious concerns about the diagnosis or plan of care

You must authorize the care

All care must be done or authorized by the participating physician group (PPG) or the primary care physician (PCP) to be a covered benefit. Separate approvals are needed for added tests, lab or x-ray services, aside from the second opinion consult. The results must be sent to the PPG or PCP for coordination.

Second opinion consults are one-time visits

Referrals for second opinion consults must be with a qualified health care professional. This means a PCP or specialist who acts within the PCP’s or specialist’s scope of practice. The PCP or specialist must have the clinical background, training and skill related to the specific illness, disease or other condition listed in the request for a second opinion.

Additional information

Relevant sections of the provider operations manuals have been revised to reflect the information in this update. Provider operations manuals are available electronically in the Provider Library, located on the provider website.

If you have questions regarding the information contained in this update, contact CalViva Health at 1-888-893-1569.