Second Opinions from PCP or specialist

A member or the member’s PCP or specialist may request a second opinion for serious medical conditions or elective surgical procedures. The conditions and/or procedures include, but are not limited to, the following:

• Treatment of serious medical conditions, such as cancer.

• Elective surgical procedures such as hernia repair (simple) for adults (age 18 or older), hysterectomy (elective procedure), spinal fusion (except for children under age 18 with a diagnosis of scoliosis) and laminectomy (except for children under 18 years old with a diagnosis of scoliosis).

• Other medically necessary conditions, including exceptions listed above, as medically necessary.

The second opinion must be obtained from a network provider (see Provider Referral Directory) or a non-network provider, if a network provider is not available, at no additional cost to the member. Prestige Health Choice must pre-authorize the use of a non-network provider for a second opinion.

Once approved, the PCP will notify the member of the date and time of the appointment and forward copies of all relevant records to the consulting provider. The PCP will notify the member of the outcome of the second opinion.

Prestige Health Choice may request a second opinion at its own discretion. This may include, but is not limited to, the following reasons:

• Whenever there is a concern about care expressed by the member or the provider;

• Whenever a potential risk or outcome related to the recommended or requested care are discovered by Prestige Health Choice during the regular course of business;

• Before initiating a denial of coverage of service;

• When denied coverage is appealed.

When Prestige Health Choice requests a second opinion, Prestige Health Choice will make the necessary arrangements for the appointment, payment and reporting. Prestige Health Choice will inform the member and the PCP of the results of the second opinion including the consulting provider’s conclusions
and recommendation(s).