Provider Directory Introduction

For assistance, please call our Member Services Department Monday – Friday, 8:00 a.m. to 6:00 p.m. at 916.536.2250, 888.563.2250 toll-free, or 888.877.5378 TTY.
 

The following notice is required by state law: Some hospitals and other providers do not provide one or more of the following services that may be covered under your plan contract and that you or your Family Member might need: family planning; contraceptive services, including emergency contraception; sterilization, including tubal ligation at the time of labor and delivery; infertility treatments or abortion. You should obtain more information before you enroll. Call your prospective doctor, medical group, independent practice association or clinic, or Member Services to make sure that you can obtain the health care services that you need.

Your PCP
In most cases, if you need non-Emergency health care, you must get this care through your PCP. Your PCP will see you for routine medical services and will arrange for the care you need from specialists and other medical providers.
Please note: that if you receive routine medical services that are not provided or coordinated by your PCP, WHA will not reimburse you for those services, except as described below.
The following services do not require a referral from your PCP:

• On-Call Physician Services: The on-call physician for your PCP can provide care in place of your PCP.
• Urgent Care: If you are in an Urgent Care situation in WHA’s service area, call your PCP for instructions, even after hours and on weekends.
• Emergency Care: If you are in an Emergency situation, please call “911” or go to the nearest hospital Emergency Room. Tell your PCP the next business day or as soon as possible.
• Gynecology Examination: You do not need a referral for routine gynecological services from a network provider.
• Obstetrical Services: You do not need a referral for obstetrical care from a network provider.
• Annual Eye Exam: You do not need a referral for an annual eye exam from a network provider.

CHOOSING A PCP
To help you choose a PCP this directory provides you with the following provider information:

• Name
• Gender
• Office location(s)
• Office email address (if available)
• Phone numbers
• Type of license/California license number
• National Provider Identifier Number
• Specialty(ies)
• Hospital admitting privileges (HAP)
• Medical group affiliation (MGA)
• Board Certifications
• Acceptance of new patients
• Non-English language(s) spoken
• Referral Programs

Here are more tips to help you choose your PCP:

• You may choose a different PCP for each family member.
• Select a PCP close enough to your home or work to allow for reasonable access to care. To find out how far away a PCP is, or for a list of providers near your address, visit choosewha.com/directory.
• Choose the type of PCP that is best for you or your family. The types of PCPs you can choose at WHA include:
  • Pediatricians
  • Family Medicine Physicians
  • Internal Medicine Physicians
  • General Practice Physicians
  • Obstetrician/Gynecologists (in some cases)
  • Nurse Practitioners (working with a PCP)
  • Physician Assistants (working with a PCP)
     

If you need assistance finding a PCP, call Member Services.

CHOOSING A FACILITY
This directory provides the following information about facilities:

• Facility name or Clinic Name
• Facility type
• Facility address
• Phone number
• Accreditation, including status (hospitals only)
• Hospital quality data (hospitals only)

Obtaining Specialty Services
In most cases, you may see a specialist only if your PCP refers you to a specialist within the WHA provider network. If there’s a particular specialist you want to see, you should let your PCP know. If your PCP refers you to a specialist, a written referral notice will be sent to you approving the visit(s) for a certain period of time. You should take this notice with you to your specialty appointment. If you receive a same-day appointment, your PCP will call, electronically transmit, or fax the referral to the specialist.
Remember, if you receive health care services from a specialist without a referral, your care will not be covered by WHA (except for OB/GYN services and annual eye exams).

STANDING REFERRALS
If you need continuing care from a specialist, you may receive a standing referral.

COORDINATION OF CARE
Remember, that in most cases your PCP will coordinate your health care with other providers. However, if you have a life-threatening, degenerative or disabling condition or disease, including HIV or AIDS and need specialized medical care over a longer period of time, you may receive a referral to a specialist or “specialty care center” that has expertise in the medical condition or disease, so the specialist can coordinate your health care. Specialists who have expertise in treating HIV or AIDS are marked with a ‡ in this Provider Directory.

ADVANTAGE REFERRAL
To give you more choices, WHA allows you to see specialists throughout our network, not only those that have a direct relationship with your PCP, medical group or IPA. If your PCP decides that you need specialty care, he/she may refer you to any of the WHA network specialists that participate in Advantage Referral. The Advantage Referral Program also includes obstetrical and gynecological services for women and annual eye exams that you receive without a referral, but as explained on page i, these services do not require a PCP referral or prior authorization. Some specialists do not participate in Advantage Referral. These are marked with a † next to their names. Note: WHA’s Advantage Referral Program is not available to UC Employees.

Behavioral Health Services
Behavioral health services, such as mental health and alcohol and drug abuse benefits, are administered through Optum Behavioral Health. If you need behavioral health treatment or have questions about your behavioral health benefits, please call Optum at 800.765.6820.
Note to University of California hospital and campus members: Your behavioral health services, including chemical dependency services, are not covered by WHA. They are covered through Optum, the supplemental coverage provided by your employer. Call Optum at 888.440.8225.

Pharmacies
WHA has a large pharmacy network through OptumRx. If you need help finding the pharmacy closest to you, visit https//www.westernhealth.com/pharmacy-information or call the Member Services Department at 916.536.2250, 888.563.2250 toll-free, or 888.877.5378 TTY. You can also reach OptumRx Toll Free Number: 1.844/568.4150 or Optum Specialty Pharmacy: 1.855.427.4682.

Explanation of Information in this Provider Directory
Acceptance of New Patients: Some network providers are currently not accepting new patients. These are marked with an asterisk (*). The medical group/IPA notifies WHA when it learns a practitioner's practice is "closed" to new patients. Quarterly, WHA requires medical groups/IPAs to validate this information. Please note that there are times that a medical group/IPA may not immediately know that a practitioner has limited his/her practice.
Hospital Accreditation: Each hospital listing includes the abbreviation “TJC,” which, stands for The Joint Commission, an entity that accredits the hospitals. To be accredited, a hospital voluntarily submits to an ongoing evaluation process to determine if it meets the standards established by an accrediting body. A hospital that is fully accredited by TJC is in full compliance with rigorous national healthcare quality and safety standards. Obtaining TJC accreditation is validation of an organization's ongoing performance improvement efforts. On a quarterly basis, WHA's contracted medical groups/IPAs are required to provide documents to support the accreditation of hospitals where they refer WHA members. WHA verifies hospital accreditation status quarterly. You may also verify a hospital’s accreditation status by visiting qualitycheck.org. To view quality information on a hospital, visit leapfroggroup.org.
Board Certifications: A specialist who has successfully completed a residency program approved by the Accreditation Council for Graduate Medical Education (ACGME) in a specialty that is recognized by the American Board of Medical Specialties (ABMS) or by the American Osteopathic Association (AOA), and has been certified by an ABMS or AOA member board, is considered board certified. Board certifications are verified by the contracted medical groups/IPAs during credentialing and re-credentialing processes, and are reported to WHA. Contracted medical groups/IPAs must verify this information for WHA, and they must notify WHA whenever a physician’s board certification status changes quarterly. The medical groups/IPAs must review and confirm the accuracy of information specific to their practitioners, including board certification quarterly. You may verify a practitioner's board certification status by visiting certificationmatters.org. Patients who would like to check the certification status of a D.O. (Doctor of Osteopathic Medicine) can contact the AOA Member Service Center at 800.621.1773, option 1 in the menu. All board certifications listed are those issued by an ABMS Board (American Board of Medical Specialties) except as follows: If "AOB" appears before the board certification, it is issued by an AOA recognized board.
Hospital Affiliations: Each listing includes the hospitals where a WHA practitioner may admit or care for patients. Practitioners self-report this information to their medical group/IPA at the time they are credentialed or recredentialed. The medical groups/IPAs report this information to WHA at that time and when a practitioner's network hospital affiliations change. Quarterly the medical groups/IPAs must review and confirm the accuracy of information specific to their practitioners, including their hospital affiliations.

Non-English Language: If a practitioner, a health care provider, other medical professional, or qualified medical interpreter speaks a language other than English, the other language is listed beneath the provider’s gender.
Languages spoken by a practitioner are self-reported and provided to WHA by the contracted medical groups/IPAs. Neither the medical groups/IPAs nor WHA verify or certify the foreign language skills of the physician.
If new information becomes known regarding a practitioner's ability to communicate in another language, the medical groups/IPAs will update this information when they return their quarterly report to WHA. If you have a specific language need, contact the physician's office directly to confirm whether they can meet your needs.
Medical Group/IPA Affiliations: Directly under the HAP is the name of the medical group(s) or IPA(s) with which the physician is associated. When a physician joins or leaves one of WHA's contracted medical groups/IPAs, the contracted medical group/IPA must notify WHA. The medical groups/IPAs must review and confirm the accuracy of information specific to their practitioners including their medical group/IPA affiliations quarterly.
Provider ID Number: Each of the PCPs listed in this directory has been assigned a Provider Number. You will find this number directly following the provider’s contact information. Use the Provider Number if you are required to enroll electronically. This computer-generated ID number is internally assigned by WHA for business purposes and other health plan related activities.
Specialty: A provider’s specialty is listed directly beneath their provider type. A specialty is a particular branch of medicine in which a practitioner focuses. A specialty may be based on a specific body system, such as the heart; a specific age group, such as pediatrics; or on a complex scientific technique used to diagnose or treat certain types of disorders. A specialist may or may not be board certified. WHA's contracted medical groups/IPAs validate specialty information during the credentialing and re-credentialing processes. They report this information to WHA at that time and as changes in specialty status occur. The medical groups/IPAs must review and confirm the accuracy of
information specific to their practitioners’ specialties quarterly.

Nurse Advice Line
WHA offers all members around-the-clock access to registered nurses who help answer questions about a medical problem they may have including:
•    Caring for minor injuries and illnesses at home.
•    Seeking the most appropriate help based on the medical concern.
•    Identifying and addressing emergency medical concerns.
They can also help you get the appropriate care you need with the right WHA healthcare providers. NurseLine services are available 24 hours a day, seven days a week by calling 877.793.3655 toll free, or 800.877.8973 TTY. Interpretation services are available.

Full and Equal Access
WHA members are entitled to full and equal access to covered services. This includes access for members with disabilities, as required under the federal Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973.

Language Assistance
If you, or someone you’re helping, have questions about Western Health Advantage, you have the right to get help and information in your language or in alternate formats at no cost. To talk to an interpreter or request an alternate format, call 888.563.2250 or TTY 888.877.5378.

Definitions of Terms Used in this Provider Directory
Emergency Medical Condition – Medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could be reasonably expected to result in any of the following:
•    Placing the patient’s health (or, in the case of a pregnant woman, the health of the woman and/or her unborn child;) in serious jeopardy;
•    Serious impairment to bodily functions; or
•    Serious dysfunction of any bodily organ or part. Emergency Medical Condition also pertains to:
•    Psychiatric screening, examination, evaluation, and treatment by a physician or other personnel, to the extent permitted by applicable law and within the scope of their licensure and privileges.
•    Care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition within the capability of a facility.
“IPA” or “Independent Practice Association” is an association made up of physicians who maintain their individual practices while agreeing as a group to accept the terms and conditions of a health plan's contracts and share risk for providing care to the health plan's members.
“Licensure” is the process by which a state admits physicians and other healthcare providers to the practice of medicine or their particular healthcare field. Licensure ensures that the person has the appropriate education and training and that they abide by recognized standards of professional conduct. WHA's contracted medical groups/IPAs have responsibility for ensuring their physicians and other healthcare providers are appropriately licensed. You may check the status of a physician license at mbc.ca.gov.
“Primary Care Physicians” or “PCPs” means a Participating Physician who:
•    Practices in the area of family practice, internal medicine, pediatrics, general practice, or obstetrics/gynecology;
•    Acts as the coordinator of care, including such responsibilities as supervising continuity of care, record keeping, and initiating referrals to Specialist Physicians for Members who select such a Primary Care Physician; and
•    Is designated as a Primary Care Physician by the Medical Group.
“Urgent Care” means services that are medically required within a short time frame, usually within twenty-four (24) hours, in order to prevent a serious deterioration of a Member’s health due to an unforeseen illness or injury. Members must contact their PCP, whenever possible, before obtaining Urgent Care services.

Accuracy
Although every effort has been made to ensure the accuracy of this Provider Directory, the information may have changed since printing.
All members, including Covered California enrollment, have access to Western Health Advantage’s full provider network. Western Health does not use quality, member experience or cost-related measures when selecting practitioners or hospitals to participate in our provider network or in our Marketplace Silver Plan.
For the most up-to-date Provider Directory, visit choosewha.com/directory or call Member Services.
Please report any inaccuracies listed in this provider directory to WHA’s Provider Relations Department at 844.870.2178 or directory@westernhealth.com.

NCQA Recognition: Patient-Centered Medical Home
The Patient-Centered Medical Home is a model of care that organizes primary care to emphasize care coordination and communication, which can transform primary care into "what patients want it to be." Medical homes use a care team approach to establish a partnership between the patient and their clinical care teams, provide enhanced access, proactive planning and follow-up, and coordination across care settings. Research* shows that PCMHs improve quality and the patient experience, and increase staff satisfaction—while reducing health care costs. Practices that earn recognition have made a commitment to continuous quality improvement and a patient-centered approach to care.
Western Health Advantage supports PCMH Recognition through its Pay for Performance program. Providers are identified on the provider directory with this recognition.
*https://www.ncqa.org/programs/health-care-providers-practices/patient-centered-medical-home-pcmh/benefits-support/pcmh-evidence/

Alternate Geographic Access Standards
The Western Health Advantage network of physicians includes participating primary care physicians (PCPs) and hospitals in Colusa, El Dorado, Humboldt, Marin, Napa, Placer, Sacramento, Solano, Sonoma and Yolo counties.

HOSPITALS BY COUNTY
Humboldt County
Providence Redwood Memorial Hospital Providence St. Joseph Hospital Eureka
Marin County
MarinHealth Medical Center
Napa County
Providence Queen of the Valley Medical Center
Sacramento County
Mercy Hospital of Folsom Mercy General Hospital
Mercy San Juan Medical Center Methodist Hospital of Sacramento

UC Davis Medical Center
Solano County
NorthBay Medical Center

NorthBay VacaValley Hospital
Sonoma County
Providence Santa Rosa Memorial Hospital Sonoma Valley Hospital
Petaluma Valley Hospital Healdsburg District Hospital
Yolo County
Woodland Memorial Hospital
 

ZIP CODES 15 MILES OR MORE FROM THE NEAREST PCP OR HOSPITAL
Many PCPs and hospitals are concentrated in the more populous areas of the counties. Members residing in the following zip codes may need to travel as indicated below to access a participating PCP or hospital.

El Dorado    95634    Georgetown    26    46
El Dorado    95636    Grizzly Flats    35    44
El Dorado    95656    Mount Aukum    24    35
El Dorado    95667    Placerville    28    30
El Dorado    95726    Pollock Pines    40    48
El Dorado    95684    Somerset    38    48

COUNTY    ZIP    CITY    Nearest PCP miles    Nearest Hospital Miles
Humboldt    95525    Blue Lake    35    35
Humboldt    95526    Bridgeville    70    60
Humboldt    95528    Carlotta    40    
Humboldt    95536    Ferndale    40    
Humboldt    95546    Hoopa    60    60
Humboldt    95549    Kneeland    35    
Humboldt    95550    Korbel    40    40
Humboldt    95565    Scotia    40    35
Humboldt    95570    Trinidad    35    35
Humboldt    95571    Weott    45    30
Humboldt    95573    Willow Creek    45    45
Marin    94920    Belvedere Tiburon    25    
Marin    94925    Corte Madera    25    
Marin    94976    Corte Madera    25    
Marin    94929    Dillon Beach    21    26
Marin    94939    Larkspur    25    
Marin    94977    Larkspur    25    
Marin    94941    Mill Valley    25    
Marin    94942    Mill Valley    25    
Marin    94964    San Quentin    25    
Marin    94901    San Rafael    25    
Marin    94912    San Rafael    25    
Marin    94915    San Rafael    25    
Marin    94965    Sausalito    25    
Marin    94966    Sausalito    25    
Marin    94970    Stinson Beach    16    17
Napa    94515    Calistoga    20    25
Napa    94558    Napa (Lake Berryessa Area)    21    24
Napa    94567    Pope Valley    23    32
Placer    95713    Colfax    21    46
Placer    95631    Foresthill    35    52
Sacramento    95638    Herald    25    33
Solano    94512    Birds Landing    30    30
Solano    94571    Rio Vista    30    
Sonoma    95412    Annapolis    48    48
Sonoma    94923    Bodega Bay    23    27
Sonoma    95430    Duncan Mills    25    21
Sonoma    95462    Monte Rio    23    34
Sonoma    95480    Stewarts Point    44    43
Sonoma    95497    The Sea Ranch    50    50
Sonoma    95486    Villa Grande    23    24
Sonoma    95421    Cazadero    46    46
Sonoma    95450    Jenner    31    

COUNTY    ZIP    CITY    Nearest PCP miles    Nearest Hospital Miles
Yolo    95606    Brooks    35    50
Yolo    95607    Capay    29    29
Yolo    95937    Dunnigan    41    40
Yolo    95627    Esparto    22    22
Yolo    95637    Guinda    39    40
Yolo    95679    Rumsey    41    45

Timely Access to Care
Health plans in California must meet timelines for providing care and services to members seeking treatment. The Timely Access Regulations set specific standards for patients to obtain a medical appointment in certain situations. The standards are shown in the chart below.
Exceptions to the Appointment Availability Standards
Preventive Care Services and Periodic Follow Up Care: Preventive care services and periodic follow up care are not subject to the appointment availability standards. These services may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of his or her practice. Periodic follow-up care includes but is not limited to, standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac or mental health conditions, and laboratory and radiological monitoring for recurrence of disease.
Extending Appointment Waiting Time: The applicable waiting time for a particular appointment may be extended if the referring or treating licensed health care provider, or the health professional providing triage or screening services, as applicable, acting within the scope of his or her practice and consistent with professionally recognized standards of practice, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the patient.
Rescheduling Appointments: When it is necessary for a provider or member to reschedule an appointment, the appointment shall be promptly rescheduled in a manner that is appropriate for the member's health care needs and ensures continuity of care consistent with good professional practice.
Advanced Access: The primary care appointment availability standard in the chart may be met if the primary care physician (PCP) office provides "advanced access.” "Advanced access" means offering an appointment to a patient with a primary care physician (or nurse practitioner or physician's assistant) within the same or next business day from the time an appointment is requested (or a later date if the patient prefers not to accept the appointment offered within the same or next business day).
If You Need Help Obtaining Timely Care
If you need help obtaining timely care:
•    First, contact your PCP or the referring provider for assistance. They may secure an appointment or find another provider that can see you sooner. Your provider may also decide that a longer waiting time will not be detrimental to your health.
•    If your provider is not able to assist, contact WHA’s Member Services.

Services that Do Not Require a Referral
WHA wants to make it easier for you to receive the right care, at the right time, and in the right place—with the best services available. The following services, when obtained from a participating provider, do not require a referral from your PCP:

•    On-call Physician Services: The on-call physician for your PCP can provide care in place of your physician.
•    Behavioral/Mental Health Services: See the back of your WHA ID card for the telephone number for your mental health benefits provider or visit mywha.org/bh.
•    Gynecology Examination/Obstetrical Services
•    Vision: An annual eye exam (when covered)
•    Emergency Care: If you are in an emergency situation, call 911 or go to the nearest hospital emergency room. Notify your PCP the next business day or as soon as possible.
•    Urgent Care: When an urgent care situation arises while you are in WHA’s Service Area, call your PCP at any time of the day, including evenings and weekends.
•    WHA also offers all members access to California-licensed, registered nurses through Nurse24. Screening, triage, and health education services are available 24 hours a day, 7 days a week. Use Nurse24 to help answer questions about a medical problem you may have, including:
•    Caring for minor injuries and illnesses at home
•    Seeking the most appropriate help based on the medical concern, including help for behavioral health concerns
•    Identifying and addressing emergency medical concerns
Interpreter services are also available upon request. Call 877.793.3655 or visit mywha.org/healthsupport to chat with a nurse or to send a secure email.

Request for Care    Routine    Urgent    Elapsed Time Standard
Visit for Primary Care            10 business days
•    Prior Authorization is required            96 hours
•    Prior Authorization is not required            48 hours
Referral for visit to medical or behavioral health specialist            15 business days
•    Prior Authorization is required            96 hours
•    Prior Authorization is not required            48 hours
Visit with non-physician behavioral health provider            10 business days
Mental Health/Substance Use Disorder Follow-Up Appointment (non-physician)            10 business days from prior appointment
Ancillary services (such as lab tests and x-rays) for diagnosis or treatment of injury, illness or other health condition.    
        15 business days
Telephone triage and screening services with a health professional*.    
    
    Waiting time cannot exceed 30 minutes
Speaking with a WHA member service representative by phone during normal business hours.    
    
    Waiting time cannot exceed 10 minutes
*WHA members can reach the NurseLine nurse advice line 24 hours per day, 7 days per week, 365 days per year by calling 877.793.3655 toll-free or 888.877.8793 TTY.

Cultural and Linguistic Services
WHA and our providers support your right to obtain accessible health care. If you have needs with regard to your culture, language, or a disability, please contact your physician’s office first or call WHA’s Member Services.

If you need assistance in a language other than English, your doctor’s office and WHA offers interpretation services in many languages, including Spanish and American Sign Language—let your physician’s office know when you call for an appointment. View the Notice of Language Assistance for more information and assistance from Member Services. The deaf and hard of hearing may use their provider’s or WHA’s TTY line at 888.877.8793 or by dialing 711.
Additional information about access to care and how to obtain a referral or prior authorization is available at mywha.org/planbasics and your EOC.