1383.15
. (a) When requested by an enrollee or participating health
professional who is treating an enrollee, a health care service plan
shall provide or authorize a second opinion by an appropriately
qualified health care professional. Reasons for a second opinion to
be provided or authorized shall include, but are not limited to, the
following:
(1) If the enrollee questions the reasonableness or necessity of
recommended surgical procedures.
(2) If the enrollee questions a diagnosis or plan of care for a
condition that threatens loss of life, loss of limb, loss of bodily
function, or substantial impairment, including, but not limited to, a
serious chronic condition.
(3) If the clinical indications are not clear or are complex and
confusing, a diagnosis is in doubt due to conflicting test results,
or the treating health professional is unable to diagnose the
condition, and the enrollee requests an additional diagnosis.
(4) If the treatment plan in progress is not improving the medical
condition of the enrollee within an appropriate period of time given
the diagnosis and plan of care, and the enrollee requests a second
opinion regarding the diagnosis or continuance of the treatment.
(5) If the enrollee has attempted to follow the plan of care or
consulted with the initial provider concerning serious concerns about
the diagnosis or plan of care.
(b) For purposes of this section, an appropriately qualified
health care professional is a primary care physician or specialist
who is acting within his or her scope of practice and who possesses a
clinical background, including training and expertise, related to
the particular illness, disease, condition or conditions associated
with the request for a second opinion. For purposes of a specialized
health care service plan, an appropriately qualified health care
professional is a licensed health care provider who is acting within
his or her scope of practice and who possesses a clinical background,
including training and expertise, related to the particular illness,
disease, condition or conditions associated with the request for a
second opinion.
(c) If an enrollee or participating health professional who is
treating an enrollee requests a second opinion pursuant to this
section, an authorization or denial shall be provided in an
expeditious manner. When the enrollee's condition is such that the
enrollee faces an imminent and serious threat to his or her health,
including, but not limited to, the potential loss of life, limb, or
other major bodily function, or lack of timeliness that would be
detrimental to the enrollee's ability to regain maximum function, the
second opinion shall be authorized or denied in a timely fashion
appropriate for the nature of the enrollee's condition, not to exceed
72 hours after the plan's receipt of the request, whenever possible.
Each plan shall file with the Department of Managed Health Care
timelines for responding to requests for second opinions for cases
involving emergency needs, urgent care, and other requests by July 1,
2000, and within 30 days of any amendment to the timelines. The
timelines shall be made available to the public upon request.
(d) If a health care service plan approves a request by an
enrollee for a second opinion, the enrollee shall be responsible only
for the costs of applicable copayments that the plan requires for
similar referrals.
(e) If the enrollee is requesting a second opinion about care from
his or her primary care physician, the second opinion shall be
provided by an appropriately qualified health care professional of
the enrollee's choice within the same physician organization.
(f) If the enrollee is requesting a second opinion about care from
a specialist, the second opinion shall be provided by any provider
of the enrollee's choice from any independent practice association or
medical group within the network of the same or equivalent
specialty. If the specialist is not within the same physician
organization, the plan shall incur the cost or negotiate the fee
arrangements of that second opinion, beyond the applicable copayments
which shall be paid by the enrollee. If not authorized by the plan,
additional medical opinions not within the original physician
organization shall be the responsibility of the enrollee.
(g) If there is no participating plan provider within the network
who meets the standard specified in subdivision (b), then the plan
shall authorize a second opinion by an appropriately qualified health
professional outside of the plan's provider network. In approving a
second opinion either inside or outside of the plan's provider
network, the plan shall take into account the ability of the enrollee
to travel to the provider.
(h) The health care service plan shall require the second opinion
health professional to provide the enrollee and the initial health
professional with a consultation report, including any recommended
procedures or tests that the second opinion health professional
believes appropriate. Nothing in this section shall be construed to
prevent the plan from authorizing, based on its independent
determination, additional medical opinions concerning the medical
condition of an enrollee.
(i) If the health care service plan denies a request by an
enrollee for a second opinion, it shall notify the enrollee in
writing of the reasons for the denial and shall inform the enrollee
of the right to file a grievance with the plan. The notice shall
comply with subdivision (b) of Section 1368.02.
(j) Unless authorized by the plan, in order for services to be
covered the enrollee shall obtain services only from a provider who
is participating in, or under contract with, the plan pursuant to the
specific contract under which the enrollee is entitled to health
care services. The plan may limit referrals to its network of
providers if there is a participating plan provider who meets the
standard specified in subdivision (b).
(k) This section shall not apply to health care service plan
contracts that provide benefits to enrollees through preferred
provider contracting arrangements if, subject to all other terms and
conditions of the contract that apply generally to all other
benefits, access to and coverage for second opinions are not limited.