Second opinion consult referral process
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Governs when and how members may obtain a one-time second opinion consult and what authorization/referral steps providers must follow; applies to Physicians and Participating Physician Groups and, for Medi‑Cal, specified counties.
No material clinical or coverage changes in this revision.
Second Opinion Coverage Criteria
Second opinion coverage criteria
Second opinion consults are covered as a one-time visit when ALL of the following are met and the consult is authorized by the participating physician group (PPG) or the primary care physician (PCP):
ALL of the following
ONE of
- Member questions the reasonableness or necessity of recommended surgical procedures.
- Member questions a diagnosis or plan of care for a condition that threatens loss of life, limb, bodily function, or major damage, including a serious chronic condition.
- Clinical signs are not clear or are complex, a diagnosis is in doubt due to conflicting test results, or the treating physician cannot diagnose the condition, and the member requests an additional diagnosis.
- Treatment plan is in progress, but the medical condition is not improving in a reasonable amount of time based on the diagnosis and plan of care.
- Member has attempted to follow the plan of care or has talked with the initial provider with serious concerns about the diagnosis or plan of care.
- Referral must be to a qualified health care professional (a PCP or specialist acting within their scope of practice with the clinical background, training and skill related to the specific illness, disease or condition listed in the request).
Referrals for second opinions must be with a qualified health care professional as defined in policy.
- All care must be done or authorized by the participating physician group (PPG) or the primary care physician (PCP).
Separate approvals are required for any added tests, lab or x‑ray services beyond the second opinion consult; results must be sent to the PPG or PCP for coordination.
Coding and Frequency
| No codes listed |
Authorization and Provider Responsibilities
Authorization required by PPG or PCP
All care must be done or authorized by the participating physician group (PPG) or the primary care physician (PCP) to be a covered benefit. Separate approvals are required for any additional tests, lab, or x‑ray services beyond the second opinion consult. Results of the consult must be sent to the PPG or PCP for coordination.
- Authorization by PPG or PCP is required for coverage.
- Separate approvals needed for added tests, lab, or x‑ray services.
- Consult results must be sent to the PPG or PCP for coordination.
Provider Services contact (questions)
For questions about this update, contact the Health Net Medi‑Cal Provider Services Center within 60 days at 1‑800‑675‑6110.
- Contact window: within 60 days.
- Phone: 1‑800‑675‑6110.
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.