55 Pa. Code § 1150.60 - Second opinion program

(a) Except as specified in subsection (g), a practitioner is required to refer a recipient to the Department to arrange an appointment for a second opinion when the proposed procedure is one that automatically requires a second opinion.

(b) The Department may require a recipient to obtain a second opinion if the Department's physicians question the medical necessity of performing the procedure through the PSR program under § 1150.59 (relating to PSR program).

(c) The Department will provide the recipient with the names of practitioners within the recipient's vicinity who are approved to provide a second opinion. The Department will arrange an appointment with the practitioner the recipient chooses. The arrangement for the appointment will be completed no later than 6 working days after the request by the recipient or the recipient's agent.

(d) After the recipient obtains a second opinion, the final decision on whether or not to have the procedure performed will be made by the recipient, even if the second opinion is contrary to the opinion of the attending practitioner. If the recipient decides to undergo the procedure, the Department will make payment in accordance with the Department's applicable payment regulations.

(e) If the recipient fails to obtain a second opinion required in subsection (a) or (b), the Department will not precertify the admission.

(f) A second opinion is not required if one of the following conditions applies:

(1) The procedure is documented in the recipient's medical record as an emergency or urgent admission by the attending practitioner and that immediate or prompt surgery is medically indicated.

(2) The patient is enrolled in a comprehensive health services plan or a capitated physician case management program.

(3) The patient is also covered by another health insurance and has obtained a second opinion under that program for the procedure for which MA coverage is sought.

(4) Another health insurance is expected to make payment for the service and MA is not expected to make an additional payment.

(5) The patient was not eligible for MA at the time the procedure was performed but subsequently became eligible.

(6) The Department has approved the admission of a recipient to a hospital and during the hospital stay it is determined that the recipient needs a surgical procedure that would otherwise require a second opinion under subsection (a) or (b).

(g) The Department will grant a waiver of the second opinion requirement specified in subsection (a) if the Department determines that one of the following applies:

(1) No qualified practitioner is available to give a second opinion.

(2) The recipient would have to travel more than 50 miles to obtain a second opinion.

(3) The recipient's medical condition is such that the travel to obtain a second opinion would result in a medical hardship for the recipient, such as when the recipient's medical condition confines the recipient to his home environment.

Notes

55 Pa. Code § 1150.60

The provisions of this § 1150.60 adopted August 11, 1989, effective immediately and apply retroactively to March 1, 1989, 19 Pa.B. 3391.

The provisions of this § 1150.60 issued under sections 443.1(1) and (4), 443.2(2)(ii) and 443.4 of the Public Welfare Code (62 P. S. §§ 443.1(1) and (4), 443.2(2)(ii) and 443.4).

This section cited in 55 Pa. Code § 1150.59 (relating to PSR program).