Second Opinion
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Published: October, 2001
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At any time during the course of treatment, the PBH case
manager, member, or provider may submit a request for a second
opinion to PBH either in writing or verbally. Second opinions
may be requested for many reasons, including situations in
which:
1) There is a question regarding the reasonableness or
necessity of recommended procedures;
2) There is a question regarding a diagnosis or plan for
care for a condition that threatens loss of life, loss of
limb, loss of bodily functions, or substantial impairment,
including but not limited to a chronic condition;
3) The clinical indications are not clear or are complex
and confusing, a diagnosis is in doubt due to conflicting
test results, or the treating provider is unable to diagnose
the condition and the member requests an additional diagnosis;
4) The treatment plan in progress is not improving the
medical condition of the member within an appropriate period
of time given the diagnosis and plan of care, and the member
requests a second opinion regarding the diagnosis or continuance
of the treatment; or
5) The member has attempted to follow the plan of care
or consulted with the initial provider concerning serious
concerns about the diagnosis or plan of care.
The request for a second opinion will be approved or denied
by PBH's Medical Director or designee in a timely fashion
appropriate for the nature of the condition. Second opinions
can only be rendered by providers qualified to review and
treat the medical condition in question. Requests for referrals
to non-participating providers for second opinions will be
considered only in the event that the services requested are
not available within the contracted network of providers.
All second opinions will be documented by a consultation
report which will be made available to all parties. If the
provider giving the second opinion recommends a particular
treatment, diagnostic test or service covered by PBH, and
it is determined to be medically necessary by the member's
participating provider, then that treatment, diagnostic test
or service will be provided or arranged by the member's participating
provider. However, the fact that the provider furnishing the
second opinion recommends a particular treatment, diagnostic
test or service does not necessarily mean that the treatment,
diagnostic test or service is medically necessary or a covered
service under the Plan. The member is only responsible for
the applicable copayment amount associated with their plan.
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