Notification to Providers and Patients

Breast Cancer (SB-5)

Upon referral by a member's primary care physician, Heritage Provider Network, Inc. will provide screening for the diagnosis of, and treatment for breast cancer, consistent with generally accepted medical practice and scientific evidence.  In order to acheive symmetry after a mastectomy, prosthetic devices and reconstructive surgery will be covered benefits.

Psychiatric Emergency medical Condition (SB349)

Heritage Provider Network, Inc. will authorize/cover all claims for "emergency services and care" for mental health conditions, which do not include a medical condition.  Emergency services will include a screening exam to determine if a psychiatric emergency exists and to provide treatment to stabilize the patient.  The intention of this law is to clarify the definition of "emergency services and care".

Cancer Screening Test (SB205)

Heritage Provider Network will provide coverage for all generally medically accepted cancer-screening tests.  HPN, Inc. will use US Task Force and AMerica Cancer Society's published guidelines to identify those cancer screening tests that are "generally medically accepted".

PKU (SB148)

Heritage Provider Network, Inc. will provide coverage for the testing and treatment of PKU under the terms and conditions of the health plan or policy.

Second Opinions (AB12)

Heritage Provider Network, Inc. will provide or authorize a second opinion by a qualified primary care physician or specialist under certain conditions.  These conditions include:

1. If the member questions the reasonableness or necessity of a recommended surgical procedure
2. If the member questions a deagnosis 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 deagnose the condition, and the member requests an additional diagnosis.
4. If the treatment plan in progress is not improving the medical condiontof the member within an appropriate period of time given the diagnosis and planof care, and the member requests a second opinion regarding the diagnosis or continuance of the treatment
5. If the member has attempted to follow the plan of care or consulted with the initial provider concerning serious concerns about the diagnosis or plan of care

If the member's condition is an imminent and serious threat to health, this second opinion must be provided within 72 hours, whenever possible.  If the second opinion is regarding PCP care, the member must seek a second opinion from their assigned medical group/IPA.

If the second opinion is regarding specialty care, the member can request the 2nd opinion from any provider within the plan's network who has the same or equivalent specialty.  Out of network requests outside of the medical group panel will be forwarded to the health plan for review.