Requests for a Second Medical Opinion
Second Opinion is a consultation by a physician other than the member’s Primary Care Physician, whose specialty is appropriate to the need, and whose services are obtained when the member disputes the appropriateness or necessity of a surgical procedure, is subject to a serious injury or illness, including failure to respond to the current treatment plan.
The member will be advised to contact the Primary Care Physician (PCP) and request a consultation with the necessary specialty provider. The member may select a contracted provider listed in the provider directory supplied by SHP or a non-contracted provider in the Plan’s geographic area. The UM Coordinator will contact the member’s PCP, or admitting physician if the member is in the hospital if necessary to assist in the second opinion process.
SHP shall pay the amount of all charges which are usual, reasonable and customary in the community for second opinion services performed by a physician not under contract with SHP, but the member may be responsible for part of the bill. SHP’s physician’s professional judgment concerning the treatment of a member derived after review of a second medical/surgical opinion shall be controlling as to the treatment obligations of
SHP.
Treatment not authorized by SHP is at the member’s expense.
Any tests/procedures deemed necessary by a second opinion consultant, and/or non-contract physician, are to be performed by an SHP-contracted provider. The UM Department will coordinate the care between the provider and the member to ensure continuity of care. The Medical Director may choose to deny reimbursement rights granted as above in the event the member seeks in excess of three (3) such referrals per year if such subsequent referrals costs are deemed by SHP to be evidence that the member has unreasonably over-utilized the second opinion privilege. A member thus denied reimbursement under this section should have recourse to grievance procedures
