CALIFORNIA - Pacificare Health Systems

PART A
10
Either you or your treating Participating Provider
may submit a request for a second medical opinion.
Requests should be submitted to your Participating
Medical Group; however, in some cases, the request
is submitted to PacifiCare. To find out how you
should submit your request, talk to your Primary Care
Physician.
Second medical opinions will be provided or
authorized in the following circumstances:
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Seeing the Doctor
When you question the reasonableness or necessity
of recommended surgical procedures;
When you question a diagnosis or treatment plan
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);
When the clinical indications are not clear, or are
complex and confusing;
When a diagnosis is in doubt due to conflicting test
results;
When the treating Provider is unable to diagnose
the condition;
When the treatment plan in progress is not
improving your medical condition within an
appropriate period of time given the diagnosis,
and you request a second opinion regarding the
diagnosis or continuance of the treatment;
When you have attempted to follow the treatment
plan or consulted with the initial Provider and
still have serious concerns about the diagnosis or
treatment.
Either the Participating Medical Group or, if applicable,
a PacifiCare Medical Director will approve or deny a
request for a second medical opinion. The request will
be approved or denied in a timely fashion appropriate
to the nature of your condition. For circumstances
other than an imminent or serious threat to your
health, a second medical opinion request will be
approved or denied within five (5) business days after
the request is received by the Participating Medical
Group or PacifiCare.
When there is an imminent and serious threat to your
health, a decision about your second opinion will be
made within 72 hours after receipt of the request by
your Participating Medical Group or PacifiCare. An
imminent and serious threat includes the potential loss
of life, limb or other major bodily function, or where a
lack of timeliness would be detrimental to your ability
to regain maximum function.
If you are requesting a second medical opinion about
care given by your Primary Care Physician, the second
medical opinion will be provided by an appropriately
qualified health care professional of your choice
within the same Participating Medical Group. (If your
Primary Care Physician is independently contracted
with PacifiCare and not affiliated with any Participating
Medical Group, you may request a second opinion
from a Primary Care Physician or specialist listed in our
Provider Directory.) If you request a second medical
opinion about care received from a specialist, the
second medical opinion will be provided by any health
care professional of your choice from any medical
group within the PacifiCare Participating Provider
network of the same or equivalent specialty.
The second medical opinion will be documented in
a consultation report which will be made available
to you and your treating Participating Provider. It
will include any recommended procedures or tests
that the Provider giving the second opinion believes
are appropriate. If this second medical opinion
includes a recommendation for a particular treatment,
diagnostic test or service covered by PacifiCare – and
the recommendation is determined to be Medically
Necessary by your Participating Medical Group or
PacifiCare – the treatment, diagnostic test or service
will be provided or arranged by your Participating
Medical Group or PacifiCare.
PLEASE NOTE: The fact that an appropriately
qualified Provider gives a second medical opinion
and recommends a particular treatment, diagnostic
test or service does not necessarily mean that the
recommended action is Medically Necessary or a
Covered Service. You will also remain responsible
for paying any outpatient office Copayments to the
Provider who gives your second medical opinion.
If your request for a second medical opinion is
denied, PacifiCare will notify you in writing and
provide the reasons for the denial. You may appeal
the denial by following the procedures outlined in
Section 9. Overseeing Your Health Care Decisions.
If you obtain a second medical opinion without
Preauthorization from your Participating Medical