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).
Learn Medical Billing Process, Tips to best AR Specialist. Medical Insurance Billing codes, Denial, procedure code and ICD 10, coverage guidelines. Demographic, charge, payment entry, AR process and eligibility and follow up. How to Guide.
Pages
- Home
- Medical Billing Question and Answer - Terms
- Insurance Denial Claim Appeal Guidelines.
- Medical Billing Downloads
- Understand Medical Billing
- Medical Billing Outsource
- Medicare Coverage and Plan Overview
- Advertise with us
- EVALUATION AND MANAGEMENT CPT code [99201-99499] - Full List
- Overall Medical billing process
- CPT Code 99201, 99202, 99203, 99204, 99205 - Which code to USE
- Internal Medical Billing Audit - how to do

Subscribe to:
Post Comments (Atom)
Medical Billing Popular Articles
-
CPT CODE AND Description 99391 - Periodic comprehensive preventive medicine reevaluation and management of an individual including an age...
-
Procedure CODES and Descriptions 99401 - Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an indi...
-
CPT Code and description 99381 - Initial comprehensive preventive medicine evaluation and management of an individual including an age an...
-
CPT code and description 80050 - General health panel This panel must include the following: Comprehensive metabolic panel (80053), ...
-
Procedure code and Description 99251 Inpatient consultation for a new or established patient, which requires these 3 key components: A pro...
-
Medicare denial code and Descripiton 1 Deductible Amount 2 Coinsurance Amount 3 Co-payment Amount 4 The procedure code is inconsistent ...
-
93000-93010: Hone Your ECG Coding Skills With 3 Essential Pointers Whether you call them ECGs or EKGs, chances are you see a lot of elec...
-
When an ERA is received, providers may: •Post decision and payment information automatically, for individual claims included in an R...
-
Billed amount: It is the Amount charged for each service performed by the provider. In other words it is the total charge value of the cla...
-
Background: Type of Service (TOS) is an indicator that the contractor places on the Form CMS-1500 paper form or electronic format. The indic...

No comments:
Post a Comment