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.
