Access Dental Plan members are entitled to a second opinion for their treatments. A request for a second opinion may also be submitted to Access by a participating PCD or any other participating provider such as a specialist, who is treating a member.

If a member requests a second opinion, your office should contact Access and request a referral to another provider. Access will then provide the member with an authorization to obtain a second opinion.

If a member is requesting a second opinion about care from his or her PCD, the second opinion shall be provided by an appropriately qualified dental provider of the member's choice within Access' network. An appropriately qualified health care professional means a primary care dentist, specialist, or other licensed health care provider who meets these requirements.

If a member is requesting a second opinion about care from a specialist, the second opinion shall be provided by any provider of the member's choice within Access' network of the same or comparable specialty. If the specialist is not within Access' network, Access shall incur the cost or negotiate the fee arrangements of that second opinion, beyond the applicable co-payments paid by the member. If there is no participating Access provider within the network who is an appropriately qualified dentist, Access shall authorize a second opinion by an appropriately qualified dentist outside of Access' provider network. Access shall take into account the ability of the member to travel to the provider. The cost of obtaining the second opinion will be borne by Access. Providers also who are treating members can request second opinions.

The reasons for a second opinion shall include, but are not limited to the following reasons:

Member questions the reasonableness or necessity of the recommended procedures
Member questions the diagnosis or plan of care for a condition that threatens loss of life, substantial impairment, including a serious chronic condition.

The clinical indications are not clear, the provider is unable to diagnose the condition or the diagnosis is unclear due to conflicting test results and the Subscriber requests additional diagnosis.

The treatment plan in progress is not improving the dental condition of the member within an appropriate period of time given the diagnosis and the member requests a second opinion regarding the diagnosis or continuance of treatment.

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. Access shall review the reasons for the request of a second opinion and provide an authorization or a denial in an expeditious manner. The second opinion will be rendered within 72-hours from Access' receipt of request where the member's condition poses imminent and serious threat to the member's life.

Access shall require the provider who is rendering the second opinion to provide the member and the initial provider with a consultation report, including any recommended procedures or tests that this second provider deems appropriate.

In the event that Access denies a request by a member or a treating provider for a second opinion, Access shall notify the member and the provider in writing of the reasons for the denial and shall inform the member and the provider of the right to file a grievance with Access.