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  1. #1
    Join Date
    Dec 2011
    Posts
    58

    Question Requested Second Opinion but Claims Adjuster is Apparently Following Unknown Rule

    Anyone on this forum think I'm missing something?

    Requested 2nd opinion. CA informed my Dr. that I would be receiving a call from a drs office to schedule appt with the second opinion dr. What happened to the list of doctors I can choose from and the 60 days to complete the appt?

    Is there a new rule in MPN where CA dictates choice? Smh....

  2. #2
    Join Date
    Oct 2006
    Posts
    9,109

    Default Re: Requested Second Opinion but Claims Adjuster is Apparently Following Unknown Rule

    yes you are; you are confusing the request for a second opinion with QME process for resolving a disputed medical issue.
    request for a second opinion does not mean there is a dispute that requires a QME.
    if you want Qualified Medical Examination, you have to be specific as to what you are disputing.

    more on proper procedures for requesting a QME here
    http://www.dir.ca.gov/dwc/FactSheets/FactSheet_E.pdf
    Last edited by .SH; 04-04-2012 at 05:28 PM.

  3. #3
    Join Date
    Dec 2011
    Posts
    58

    Default Re: Requested Second Opinion but Claims Adjuster is Apparently Following Unknown Rule

    I am not requesting a QME. I was very specific asking for a second opinion regarding diagnosis/treatment suggested by PTP.

  4. #4
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,045

    Default Re: Requested Second Opinion but Claims Adjuster is Apparently Following Unknown Rule

    Quote Quoting heavenly View Post
    I am not requesting a QME. I was very specific asking for a second opinion regarding diagnosis/treatment suggested by PTP.
    You can request a change/second opinion in the MPN...and a third, after that you go through the IME process in the MPN. The rule is below.
    9767.7. Second and Third Opinions(a) If the covered employee disputes either the diagnosis or the treatment prescribed by the primary treating physician or the treating physician, the employee may obtain a second and third opinion from physicians within the MPN. During this process, the employee is required to continue his or her treatment with the treating physician or a physician of his or her choice within the MPN. http://www.dir.ca.gov/t8/9767_7.html

    (b) If the covered employee disputes either the diagnosis or the treatment prescribed by primary treating physician or the treating physician, it is the employee's responsibility to: (1) inform the person designated by the employer or insurer that he or she disputes the treating physician's opinion and requests a second opinion (the employee may notify the person designated by the employer or insurer either in writing or orally); (2) select a physician or specialist from a list of available MPN providers; (3) make an appointment with the second opinion physician within 60 days; and (4) inform the person designated by the employer or insurer of the appointment date. It is the employer's or insurer's responsibility to (1) provide a regional area listing of MPN providers and/or specialists to the employee for his/her selection based on the specialty or recognized expertise in treating the particular injury or condition in question and inform the employee of his or her right to request a copy of the medical records that will be sent to the second opinion physician; (2) contact the treating physician, provide a copy of the medical records or send the necessary medical records to the second opinion physician prior to the appointment date, and provide a copy of the records to the covered employee upon request; and (3) notify the second opinion physician in writing that he or she has been selected to provide a second opinion and the nature of the dispute with a copy to the employee. If the appointment is not made within 60 days of receipt of the list of the available MPN providers, then the employee shall be deemed to have waived the second opinion process with regard to this disputed diagnosis or treatment of this treating physician.
    This is NOT part of the PQME process.

  5. #5
    Join Date
    Dec 2011
    Posts
    58

    Default Re: Requested Second Opinion but Claims Adjuster is Apparently Following Unknown Rule

    BvIA~ Thank you!!!'

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