DHCS Approved Alternative Access Standards Effective July …...Dec 31, 2020 · Humboldt 95552...
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DHCS Approved Alternative Access Standards Effective July 2020 County Zip Code Provider Type Pediatric, Adult, or N/A County Size Standards MCP Requested Minutes Miles DHCS Ratioale DHCS Approved Access Standards Minutes Miles Minutes Miles 95531 ENT/Otolaryngology Adult 90 101 79 101 79 Approval Del Norte 60 95531 ENT/Otolaryngology Pediatric 90 101 79 101 79 Approval Del Norte 60 95531 PCP Adult 30 99 52 99 52 Approval Del Norte 10 95531 PCP Pediatric 30 152 53 152 53 Approval Del Norte 10 95543 ENT/Otolaryngology Adult 90 198 146 198 146 Approval Del Norte 60 95543 ENT/Otolaryngology Pediatric 90 198 146 198 146 Approval Del Norte 60 95543 Hospital N/A 30 82 63 82 63 Approval Del Norte 15 95543 PCP Adult 30 126 73 126 73 Approval Del Norte 10 95543 PCP Pediatric 30 99 68 99 68 Approval Del Norte 10 95548 ENT/Otolaryngology Adult 90 90 69 90 69 Approval Del Norte 60 95548 ENT/Otolaryngology Pediatric 90 90 69 90 69 Approval Del Norte 60 95548 Hospital N/A 30 30 28 30 28 Approval Del Norte 15 95548 PCP Adult 30 165 88 165 88 Approval Del Norte 10 95548 PCP Pediatric 30 15 15 15 15 Approval Del Norte 10 95567 ENT/Otolaryngology Adult 90 110 86 110 86 Approval Del Norte 60 95567 ENT/Otolaryngology Pediatric 90 110 86 110 86 Approval Del Norte 60 95567 Hospital N/A 30 17 17 17 17 Approval Del Norte 15 95511 Hospital N/A 30 151 90 54 26 Approval Humboldt 15 95511 PCP Adult 30 20 19 20 19 Approval Humboldt 10 95511 PCP Pediatric 30 20 19 20 19 Approval Humboldt 10 95511 Physical Medicine and Rehabilitation Adult 90 70 65 70 65 Approval Humboldt 60 Page 1 of 42 Partnership Health Plan of California 2020
Transcript of DHCS Approved Alternative Access Standards Effective July …...Dec 31, 2020 · Humboldt 95552...
DHCS Approved Alternative Access StandardsEffective July 2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RatioaleDHCS Approved Access StandardsMinutes MilesMinutes Miles
95531 ENT/Otolaryngology Adult 90 101 79 101 79 ApprovalDel Norte 60
95531 ENT/Otolaryngology Pediatric 90 101 79 101 79 ApprovalDel Norte 60
95531 PCP Adult 30 99 52 99 52 ApprovalDel Norte 10
95531 PCP Pediatric 30 152 53 152 53 ApprovalDel Norte 10
95543 ENT/Otolaryngology Adult 90 198 146 198 146 ApprovalDel Norte 60
95543 ENT/Otolaryngology Pediatric 90 198 146 198 146 ApprovalDel Norte 60
95543 Hospital N/A 30 82 63 82 63 ApprovalDel Norte 15
95543 PCP Adult 30 126 73 126 73 ApprovalDel Norte 10
95543 PCP Pediatric 30 99 68 99 68 ApprovalDel Norte 10
95548 ENT/Otolaryngology Adult 90 90 69 90 69 ApprovalDel Norte 60
95548 ENT/Otolaryngology Pediatric 90 90 69 90 69 ApprovalDel Norte 60
95548 Hospital N/A 30 30 28 30 28 ApprovalDel Norte 15
95548 PCP Adult 30 165 88 165 88 ApprovalDel Norte 10
95548 PCP Pediatric 30 15 15 15 15 ApprovalDel Norte 10
95567 ENT/Otolaryngology Adult 90 110 86 110 86 ApprovalDel Norte 60
95567 ENT/Otolaryngology Pediatric 90 110 86 110 86 ApprovalDel Norte 60
95567 Hospital N/A 30 17 17 17 17 ApprovalDel Norte 15
95511 Hospital N/A 30 151 90 54 26 ApprovalHumboldt 15
95511 PCP Adult 30 20 19 20 19 ApprovalHumboldt 10
95511 PCP Pediatric 30 20 19 20 19 ApprovalHumboldt 10
95511 Physical Medicine and Rehabilitation
Adult 90 70 65 70 65 ApprovalHumboldt 60
Page 1 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles95511 Physical Medicine and
RehabilitationPediatric 90 70 65 70 65 ApprovalHumboldt 60
95514 Hospital N/A 30 88 61 88 61 ApprovalHumboldt 15
95514 PCP Adult 30 129 47 129 47 ApprovalHumboldt 10
95514 PCP Pediatric 30 129 47 129 47 ApprovalHumboldt 10
95525 Hospital N/A 30 64 44 64 44 ApprovalHumboldt 15
95525 PCP Adult 30 65 44 65 44 ApprovalHumboldt 10
95525 PCP Pediatric 30 65 44 65 44 ApprovalHumboldt 10
95526 Hospital N/A 30 131 78 131 78 ApprovalHumboldt 15
95526 PCP Adult 30 131 78 131 78 ApprovalHumboldt 10
95526 PCP Pediatric 30 139 75 139 75 ApprovalHumboldt 10
95528 Hospital N/A 30 76 60 59 34 ApprovalHumboldt 15
95528 PCP Adult 30 18 17 18 17 ApprovalHumboldt 10
95528 PCP Pediatric 30 18 17 18 17 ApprovalHumboldt 10
95536 Hospital N/A 30 52 35 52 35 ApprovalHumboldt 15
95536 PCP Adult 30 20 19 20 19 ApprovalHumboldt 10
95536 PCP Pediatric 30 20 19 20 19 ApprovalHumboldt 10
95542 Hospital N/A 30 113 44 113 44 ApprovalHumboldt 15
95542 PCP Adult 30 84 45 84 45 ApprovalHumboldt 10
95542 PCP Pediatric 30 84 45 84 45 ApprovalHumboldt 10
95542 Physical Medicine and Rehabilitation
Adult 90 128 96 128 96 ApprovalHumboldt 60
95542 Physical Medicine and Rehabilitation
Pediatric 90 128 96 128 96 ApprovalHumboldt 60
95546 Hospital N/A 30 114 84 114 84 ApprovalHumboldt 15
Page 2 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles95546 PCP Adult 30 118 46 118 46 ApprovalHumboldt 10
95546 PCP Pediatric 30 118 46 118 46 ApprovalHumboldt 10
95549 Hospital N/A 30 90 48 90 48 ApprovalHumboldt 15
95549 PCP Adult 30 23 22 23 22 ApprovalHumboldt 10
95549 PCP Pediatric 30 23 22 23 22 ApprovalHumboldt 10
95550 Hospital N/A 30 156 69 156 69 ApprovalHumboldt 15
95550 PCP Adult 30 104 53 104 53 ApprovalHumboldt 10
95550 PCP Pediatric 30 104 53 104 53 ApprovalHumboldt 10
95552 Hospital N/A 30 153 74 153 74 ApprovalHumboldt 15
95552 PCP Adult 30 26 25 26 25 ApprovalHumboldt 10
95552 PCP Pediatric 30 64 26 130 54 ApprovalHumboldt 10
95554 Hospital N/A 30 139 73 61 40 ApprovalHumboldt 15
95554 PCP Adult 30 20 20 20 20 ApprovalHumboldt 10
95554 PCP Pediatric 30 20 20 20 20 ApprovalHumboldt 10
95555 Hospital N/A 30 37 34 37 34 ApprovalHumboldt 15
95555 PCP Adult 30 72 57 58 29 ApprovalHumboldt 10
95555 PCP Pediatric 30 72 57 72 57 ApprovalHumboldt 10
95558 Hospital N/A 30 107 51 107 51 ApprovalHumboldt 15
95558 PCP Adult 30 81 52 81 52 ApprovalHumboldt 10
95558 PCP Pediatric 30 106 52 106 52 ApprovalHumboldt 10
95565 Hospital N/A 30 33 25 108 53 ApprovalHumboldt 15
95565 PCP Adult 30 16 16 16 16 ApprovalHumboldt 10
95565 PCP Pediatric 30 16 16 16 16 ApprovalHumboldt 10
Page 3 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles95569 Hospital N/A 30 53 39 53 39 ApprovalHumboldt 15
95569 PCP Adult 30 21 20 21 20 ApprovalHumboldt 10
95569 PCP Pediatric 30 21 20 21 20 ApprovalHumboldt 10
95570 Hospital N/A 30 38 33 38 33 ApprovalHumboldt 15
95570 PCP Adult 30 20 20 20 20 ApprovalHumboldt 10
95570 PCP Pediatric 30 20 20 20 20 ApprovalHumboldt 10
95573 Hospital N/A 30 87 55 87 55 ApprovalHumboldt 15
95589 Hospital N/A 30 75 33 75 33 ApprovalHumboldt 15
95589 PCP Adult 30 90 53 90 53 ApprovalHumboldt 10
95589 PCP Pediatric 30 94 53 94 53 ApprovalHumboldt 10
95423 PCP Adult 30 119 45 119 45 ApprovalLake 10
95423 PCP Pediatric 30 119 45 119 45 ApprovalLake 10
95451 PCP Adult 30 14 13 14 13 ApprovalLake 10
95451 PCP Pediatric 30 14 13 14 13 ApprovalLake 10
95457 PCP Adult 30 14 14 14 14 ApprovalLake 10
95457 PCP Pediatric 30 15 15 15 15 ApprovalLake 10
95461 Hospital N/A 30 18 17 18 17 ApprovalLake 15
95461 PCP Adult 30 13 13 13 13 ApprovalLake 10
95461 PCP Pediatric 30 13 13 13 13 ApprovalLake 10
95469 Hospital N/A 30 105 52 105 52 ApprovalLake 15
95469 PCP Adult 30 87 49 87 49 ApprovalLake 10
95469 PCP Pediatric 30 87 49 87 49 ApprovalLake 10
95469 Physical Medicine and Rehabilitation
Adult 75 141 83 141 83 ApprovalLake 45
Page 4 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles95469 Physical Medicine and
RehabilitationPediatric 75 141 83 141 83 ApprovalLake 45
95485 PCP Adult 30 13 13 13 13 ApprovalLake 10
95485 PCP Pediatric 30 13 13 13 13 ApprovalLake 10
95493 PCP Adult 30 13 13 13 13 ApprovalLake 10
95493 PCP Pediatric 30 13 13 13 13 ApprovalLake 10
96056 ENT/Otolaryngology Adult 90 170 131 170 131 ApprovalLassen 60
96056 ENT/Otolaryngology Pediatric 90 170 131 170 131 ApprovalLassen 60
96056 Hematology Adult 90 167 126 167 126 ApprovalLassen 60
96056 Hematology Pediatric 90 145 138 145 138 ApprovalLassen 60
96056 Hospital N/A 30 98 90 98 90 ApprovalLassen 15
96056 Oncology Adult 90 167 126 167 126 ApprovalLassen 60
96056 Oncology Pediatric 90 156 138 156 138 ApprovalLassen 60
96056 Ophthalmology Adult 90 140 136 140 136 ApprovalLassen 60
96056 Ophthalmology Pediatric 90 140 136 140 136 ApprovalLassen 60
96056 PCP Adult 30 91 79 91 79 ApprovalLassen 10
96056 PCP Pediatric 30 91 79 91 79 ApprovalLassen 10
96056 Physical Medicine and Rehabilitation
Adult 90 152 137 152 137 ApprovalLassen 60
96056 Physical Medicine and Rehabilitation
Pediatric 90 158 127 158 127 ApprovalLassen 60
96109 Cardiology/Interventional Cardiology
Adult 90 69 64 69 64 ApprovalLassen 60
96109 Cardiology/Interventional Cardiology
Pediatric 90 69 64 69 64 ApprovalLassen 60
96109 Dermatology Adult 90 86 74 86 74 ApprovalLassen 60
96109 Dermatology Pediatric 90 85 74 85 74 ApprovalLassen 60
Page 5 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96109 Endocrinology Adult 90 85 74 85 74 ApprovalLassen 60
96109 Endocrinology Pediatric 90 85 74 85 74 ApprovalLassen 60
96109 ENT/Otolaryngology Adult 90 141 98 141 98 ApprovalLassen 60
96109 ENT/Otolaryngology Pediatric 90 141 98 141 98 ApprovalLassen 60
96109 Gastroenterology Adult 90 72 67 72 67 ApprovalLassen 60
96109 Gastroenterology Pediatric 90 72 67 72 67 ApprovalLassen 60
96109 General Surgery Adult 90 73 68 73 68 ApprovalLassen 60
96109 General Surgery Pediatric 90 73 68 73 68 ApprovalLassen 60
96109 Hematology Adult 90 169 151 169 151 ApprovalLassen 60
96109 Hematology Pediatric 90 169 151 169 151 ApprovalLassen 60
96109 HIV/AIDS Specialists/Infectious Diseases
Adult 90 72 67 72 67 ApprovalLassen 60
96109 HIV/AIDS Specialists/Infectious Diseases
Pediatric 90 72 67 72 67 ApprovalLassen 60
96109 Hospital N/A 30 73 67 73 67 ApprovalLassen 15
96109 Nephrology Adult 90 72 67 72 67 ApprovalLassen 60
96109 Nephrology Pediatric 90 72 67 72 67 ApprovalLassen 60
96109 Neurology Adult 90 72 67 72 67 ApprovalLassen 60
96109 Neurology Pediatric 90 72 67 72 67 ApprovalLassen 60
96109 OB/GYN N/A 90 72 67 72 67 ApprovalLassen 60
96109 Oncology Adult 90 169 151 169 151 ApprovalLassen 60
96109 Oncology Pediatric 90 169 151 169 151 ApprovalLassen 60
96109 Ophthalmology Adult 90 181 148 181 148 ApprovalLassen 60
96109 Ophthalmology Pediatric 90 181 148 181 148 ApprovalLassen 60
Page 6 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96109 Orthopedic Surgery Adult 90 72 67 72 67 ApprovalLassen 60
96109 Orthopedic Surgery Pediatric 90 72 67 72 67 ApprovalLassen 60
96109 PCP Adult 30 73 67 73 67 ApprovalLassen 10
96109 PCP Pediatric 30 73 67 73 67 ApprovalLassen 10
96109 Physical Medicine and Rehabilitation
Adult 90 198 159 198 159 ApprovalLassen 60
96109 Physical Medicine and Rehabilitation
Pediatric 90 198 159 198 159 ApprovalLassen 60
96109 Pulmonology Adult 90 69 64 69 64 ApprovalLassen 60
96109 Pulmonology Pediatric 90 69 64 69 64 ApprovalLassen 60
96114 Hematology Adult 90 156 124 156 124 ApprovalLassen 60
96114 Hematology Pediatric 90 156 124 156 124 ApprovalLassen 60
96114 Hospital N/A 30 22 21 22 21 ApprovalLassen 15
96114 Oncology Adult 90 149 118 149 118 ApprovalLassen 60
96114 Oncology Pediatric 90 149 118 149 118 ApprovalLassen 60
96114 Ophthalmology Adult 90 148 117 148 117 ApprovalLassen 60
96114 Ophthalmology Pediatric 90 148 117 148 117 ApprovalLassen 60
96114 PCP Adult 30 104 55 104 55 ApprovalLassen 10
96114 PCP Pediatric 30 99 54 99 54 ApprovalLassen 10
96114 Physical Medicine and Rehabilitation
Adult 90 161 129 161 129 ApprovalLassen 60
96114 Physical Medicine and Rehabilitation
Pediatric 90 161 129 161 129 ApprovalLassen 60
96117 Hematology Adult 90 192 148 192 148 ApprovalLassen 60
96117 Hematology Pediatric 90 192 148 192 148 ApprovalLassen 60
96117 Hospital N/A 30 66 46 66 46 ApprovalLassen 15
Page 7 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96117 Oncology Adult 90 192 148 192 148 ApprovalLassen 60
96117 Oncology Pediatric 90 192 148 192 148 ApprovalLassen 60
96117 Ophthalmology Adult 90 89 82 89 82 ApprovalLassen 60
96117 Ophthalmology Pediatric 90 89 82 89 82 ApprovalLassen 60
96117 PCP Adult 30 25 24 25 24 ApprovalLassen 10
96117 PCP Pediatric 30 25 24 25 24 ApprovalLassen 10
96117 Physical Medicine and Rehabilitation
Adult 90 203 154 203 154 ApprovalLassen 60
96117 Physical Medicine and Rehabilitation
Pediatric 90 203 154 203 154 ApprovalLassen 60
96121 Hematology Adult 90 165 134 165 134 ApprovalLassen 60
96121 Hematology Pediatric 90 165 134 165 134 ApprovalLassen 60
96121 Hospital N/A 30 39 36 39 36 ApprovalLassen 15
96121 Oncology Adult 90 162 134 162 134 ApprovalLassen 60
96121 Oncology Pediatric 90 162 134 162 134 ApprovalLassen 60
96121 Ophthalmology Adult 90 162 133 162 133 ApprovalLassen 60
96121 Ophthalmology Pediatric 90 162 133 162 133 ApprovalLassen 60
96121 PCP Adult 30 39 36 39 36 ApprovalLassen 10
96121 PCP Pediatric 30 39 36 39 36 ApprovalLassen 10
96121 Physical Medicine and Rehabilitation
Adult 90 216 150 216 150 ApprovalLassen 60
96121 Physical Medicine and Rehabilitation
Pediatric 90 211 150 211 150 ApprovalLassen 60
96123 ENT/Otolaryngology Adult 90 211 133 211 133 ApprovalLassen 60
96123 ENT/Otolaryngology Pediatric 90 211 133 211 133 ApprovalLassen 60
96123 Hematology Adult 90 263 197 263 197 ApprovalLassen 60
Page 8 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96123 Hematology Pediatric 90 263 197 263 197 ApprovalLassen 60
96123 Hospital N/A 30 131 77 131 77 ApprovalLassen 15
96123 Oncology Adult 90 265 196 265 196 ApprovalLassen 60
96123 Oncology Pediatric 90 265 196 265 196 ApprovalLassen 60
96123 Ophthalmology Adult 90 69 64 69 64 ApprovalLassen 60
96123 Ophthalmology Pediatric 90 69 64 69 64 ApprovalLassen 60
96123 Orthopedic Surgery Adult 90 145 97 145 97 ApprovalLassen 60
96123 Orthopedic Surgery Pediatric 90 145 97 145 97 ApprovalLassen 60
96123 PCP Adult 30 145 97 145 97 ApprovalLassen 10
96123 PCP Pediatric 30 141 82 141 82 ApprovalLassen 10
96123 Physical Medicine and Rehabilitation
Adult 90 230 200 215 174 ApprovalLassen 60
96123 Physical Medicine and Rehabilitation
Pediatric 90 230 200 215 174 ApprovalLassen 60
96128 Hematology Adult 90 165 130 165 130 ApprovalLassen 60
96128 Hematology Pediatric 90 165 130 165 130 ApprovalLassen 60
96128 Hospital N/A 30 22 22 22 22 ApprovalLassen 15
96128 Oncology Adult 90 165 130 165 130 ApprovalLassen 60
96128 Oncology Pediatric 90 165 130 165 130 ApprovalLassen 60
96128 Ophthalmology Adult 90 90 84 90 84 ApprovalLassen 60
96128 Ophthalmology Pediatric 90 90 84 90 84 ApprovalLassen 60
96128 PCP Adult 30 22 21 22 21 ApprovalLassen 10
96128 PCP Pediatric 30 22 21 22 21 ApprovalLassen 10
96128 Physical Medicine and Rehabilitation
Adult 90 158 130 158 130 ApprovalLassen 60
Page 9 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96128 Physical Medicine and
RehabilitationPediatric 90 171 135 171 135 ApprovalLassen 60
96130 Hematology Adult 90 205 164 205 164 ApprovalLassen 60
96130 Hematology Pediatric 90 205 164 205 164 ApprovalLassen 60
96130 Hospital N/A 30 107 78 107 78 ApprovalLassen 15
96130 Oncology Adult 90 227 173 227 173 ApprovalLassen 60
96130 Oncology Pediatric 90 227 173 227 173 ApprovalLassen 60
96130 Ophthalmology Adult 90 203 162 203 162 ApprovalLassen 60
96130 Ophthalmology Pediatric 90 203 162 203 162 ApprovalLassen 60
96130 PCP Adult 30 60 60 60 60 ApprovalLassen 10
96130 PCP Pediatric 30 61 60 61 60 ApprovalLassen 10
96130 Physical Medicine and Rehabilitation
Adult 90 227 174 227 174 ApprovalLassen 60
96130 Physical Medicine and Rehabilitation
Pediatric 90 226 173 226 173 ApprovalLassen 60
96132 ENT/Otolaryngology Adult 90 242 136 242 136 ApprovalLassen 60
96132 ENT/Otolaryngology Pediatric 90 242 136 242 136 ApprovalLassen 60
96132 Hematology Adult 90 248 182 248 182 ApprovalLassen 60
96132 Hematology Pediatric 90 248 182 248 182 ApprovalLassen 60
96132 Hospital N/A 30 69 64 69 64 ApprovalLassen 15
96132 Oncology Adult 90 248 182 248 182 ApprovalLassen 60
96132 Oncology Pediatric 90 248 182 248 182 ApprovalLassen 60
96132 PCP Adult 30 66 63 66 63 ApprovalLassen 10
96132 PCP Pediatric 30 66 63 66 63 ApprovalLassen 10
96132 Physical Medicine and Rehabilitation
Adult 90 250 182 250 182 ApprovalLassen 60
Page 10 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96132 Physical Medicine and
RehabilitationPediatric 90 250 182 250 182 ApprovalLassen 60
96136 Hematology Adult 90 179 134 179 134 ApprovalLassen 60
96136 Hematology Pediatric 90 179 134 179 134 ApprovalLassen 60
96136 Hospital N/A 30 26 25 26 25 ApprovalLassen 15
96136 Oncology Adult 90 178 134 178 134 ApprovalLassen 60
96136 Oncology Pediatric 90 178 134 178 134 ApprovalLassen 60
96136 Ophthalmology Adult 90 94 86 94 86 ApprovalLassen 60
96136 Ophthalmology Pediatric 90 94 86 94 86 ApprovalLassen 60
96136 PCP Adult 30 26 25 26 25 ApprovalLassen 10
96136 PCP Pediatric 30 26 25 26 25 ApprovalLassen 10
96136 Physical Medicine and Rehabilitation
Adult 90 186 139 186 139 ApprovalLassen 60
96136 Physical Medicine and Rehabilitation
Pediatric 90 186 139 186 139 ApprovalLassen 60
96137 Hematology Adult 90 166 121 166 122 ApprovalLassen 60
96137 Hematology Pediatric 90 166 121 166 121 ApprovalLassen 60
96137 Hospital N/A 30 33 30 33 30 ApprovalLassen 15
96137 Oncology Adult 90 73 68 73 68 ApprovalLassen 60
96137 Oncology Pediatric 90 73 68 73 68 ApprovalLassen 60
96137 Ophthalmology Adult 90 74 69 74 69 ApprovalLassen 60
96137 Ophthalmology Pediatric 90 74 69 74 69 ApprovalLassen 60
94937 Hospital N/A 30 86 42 86 42 ApprovalMarin 15
94937 PCP Adult 30 16 16 16 16 ApprovalMarin 10
94937 PCP Pediatric 30 16 16 16 16 ApprovalMarin 10
Page 11 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles94940 Hospital N/A 30 21 20 21 20 ApprovalMarin 15
94940 PCP Adult 30 15 15 15 15 ApprovalMarin 10
94940 PCP Pediatric 30 15 15 15 15 ApprovalMarin 10
94952 Hospital N/A 30 18 17 18 17 ApprovalMarin 15
94952 PCP Adult 30 13 12 13 12 ApprovalMarin 10
94952 PCP Pediatric 30 13 12 13 12 ApprovalMarin 10
94956 Hospital N/A 30 23 22 23 22 ApprovalMarin 15
95410 Hospital N/A 30 26 25 26 25 ApprovalMendocino 15
95410 PCP Adult 30 25 24 25 24 ApprovalMendocino 10
95410 PCP Pediatric 30 25 24 25 24 ApprovalMendocino 10
95410 Physical Medicine and Rehabilitation
Adult 90 130 98 130 98 ApprovalMendocino 60
95410 Physical Medicine and Rehabilitation
Pediatric 90 130 98 130 98 ApprovalMendocino 60
95415 Hospital N/A 30 24 23 24 23 ApprovalMendocino 15
95417 Hospital N/A 30 88 61 88 61 ApprovalMendocino 15
95417 PCP Adult 30 18 18 18 18 ApprovalMendocino 10
95417 PCP Pediatric 30 18 18 18 18 ApprovalMendocino 10
95417 Physical Medicine and Rehabilitation
Adult 90 141 116 141 116 ApprovalMendocino 60
95417 Physical Medicine and Rehabilitation
Pediatric 90 141 116 141 116 ApprovalMendocino 60
95420 Physical Medicine and Rehabilitation
Adult 90 128 100 128 100 ApprovalMendocino 60
95420 Physical Medicine and Rehabilitation
Pediatric 90 128 100 128 100 ApprovalMendocino 60
95425 Hospital N/A 30 26 25 26 25 ApprovalMendocino 15
95427 Hospital N/A 30 25 24 25 24 ApprovalMendocino 15
Page 12 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles95427 PCP Adult 30 23 22 23 22 ApprovalMendocino 10
95427 PCP Pediatric 30 23 22 23 22 ApprovalMendocino 10
95427 Physical Medicine and Rehabilitation
Adult 90 77 71 77 71 ApprovalMendocino 60
95427 Physical Medicine and Rehabilitation
Pediatric 90 77 71 77 71 ApprovalMendocino 60
95428 Hospital N/A 30 139 74 139 74 ApprovalMendocino 15
95428 PCP Adult 30 121 49 121 49 ApprovalMendocino 10
95428 PCP Pediatric 30 121 49 121 49 ApprovalMendocino 10
95428 Physical Medicine and Rehabilitation
Adult 90 275 178 275 178 ApprovalMendocino 60
95428 Physical Medicine and Rehabilitation
Pediatric 90 275 178 275 168 ApprovalMendocino 60
95429 Hospital N/A 30 29 28 29 28 ApprovalMendocino 15
95429 PCP Adult 30 13 13 13 13 ApprovalMendocino 10
95429 PCP Pediatric 30 13 13 13 13 ApprovalMendocino 10
95429 Physical Medicine and Rehabilitation
Adult 90 118 100 118 100 ApprovalMendocino 60
95429 Physical Medicine and Rehabilitation
Pediatric 90 118 100 118 100 ApprovalMendocino 60
95432 Hospital N/A 30 32 30 32 30 ApprovalMendocino 15
95432 PCP Adult 30 21 21 21 21 ApprovalMendocino 10
95432 PCP Pediatric 30 21 21 21 21 ApprovalMendocino 10
95432 Physical Medicine and Rehabilitation
Adult 90 128 100 128 100 ApprovalMendocino 60
95432 Physical Medicine and Rehabilitation
Pediatric 90 124 102 124 102 ApprovalMendocino 60
95437 Physical Medicine and Rehabilitation
Adult 90 153 116 153 116 ApprovalMendocino 60
95437 Physical Medicine and Rehabilitation
Pediatric 90 153 116 153 116 ApprovalMendocino 60
95445 Hospital N/A 30 94 69 94 69 ApprovalMendocino 15
Page 13 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles95449 Hospital N/A 30 23 22 23 22 ApprovalMendocino 15
95454 ENT/Otolaryngology Adult 90 67 62 67 62 ApprovalMendocino 60
95454 ENT/Otolaryngology Pediatric 90 67 62 67 62 ApprovalMendocino 60
95454 Hospital N/A 30 76 63 76 63 ApprovalMendocino 15
95454 PCP Adult 30 21 20 21 20 ApprovalMendocino 10
95454 PCP Pediatric 30 21 20 21 20 ApprovalMendocino 10
95454 Physical Medicine and Rehabilitation
Adult 90 91 84 91 84 ApprovalMendocino 60
95454 Physical Medicine and Rehabilitation
Pediatric 90 91 84 91 84 ApprovalMendocino 60
95456 Hospital N/A 30 47 27 47 27 ApprovalMendocino 15
95456 PCP Adult 30 18 18 18 18 ApprovalMendocino 10
95456 PCP Pediatric 30 18 18 18 18 ApprovalMendocino 10
95456 Physical Medicine and Rehabilitation
Adult 90 124 101 124 101 ApprovalMendocino 60
95456 Physical Medicine and Rehabilitation
Pediatric 90 119 98 119 98 ApprovalMendocino 60
95459 Hospital N/A 30 40 37 40 37 ApprovalMendocino 15
95459 PCP Adult 30 15 15 15 15 ApprovalMendocino 10
95459 PCP Pediatric 30 15 15 15 15 ApprovalMendocino 10
95460 Hospital N/A 30 36 23 36 23 ApprovalMendocino 15
95460 PCP Adult 30 17 17 17 17 ApprovalMendocino 10
95460 PCP Pediatric 30 17 17 17 17 ApprovalMendocino 10
95460 Physical Medicine and Rehabilitation
Adult 90 144 111 144 111 ApprovalMendocino 60
95460 Physical Medicine and Rehabilitation
Pediatric 90 143 109 143 109 ApprovalMendocino 60
95463 Hospital N/A 30 20 19 20 19 ApprovalMendocino 15
Page 14 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles95463 PCP Adult 30 18 17 18 17 ApprovalMendocino 10
95463 PCP Pediatric 30 18 17 18 17 ApprovalMendocino 10
95466 Hospital N/A 30 28 27 28 27 ApprovalMendocino 15
95466 PCP Adult 30 23 22 23 22 ApprovalMendocino 10
95466 PCP Pediatric 30 23 22 23 22 ApprovalMendocino 10
95468 Hospital N/A 30 44 41 44 41 ApprovalMendocino 15
95468 PCP Adult 30 66 39 66 39 ApprovalMendocino 10
95468 PCP Pediatric 30 66 39 66 39 ApprovalMendocino 10
95469 Hospital N/A 30 105 47 105 47 ApprovalMendocino 15
95469 PCP Adult 30 87 49 87 49 ApprovalMendocino 10
95469 PCP Pediatric 30 87 49 87 49 ApprovalMendocino 10
95488 ENT/Otolaryngology Adult 90 68 63 68 63 ApprovalMendocino 60
95488 ENT/Otolaryngology Pediatric 90 68 63 68 63 ApprovalMendocino 60
95488 Hospital N/A 30 88 67 59 32 ApprovalMendocino 15
95488 PCP Adult 30 23 22 23 22 ApprovalMendocino 10
95488 PCP Pediatric 30 23 22 23 22 ApprovalMendocino 10
95488 Physical Medicine and Rehabilitation
Adult 90 164 135 164 135 ApprovalMendocino 60
95488 Physical Medicine and Rehabilitation
Pediatric 90 164 135 164 135 ApprovalMendocino 60
95490 Hospital N/A 30 59 48 59 48 ApprovalMendocino 15
95490 PCP Adult 30 14 13 14 13 ApprovalMendocino 10
95490 PCP Pediatric 30 14 13 14 13 ApprovalMendocino 10
95490 Physical Medicine and Rehabilitation
Adult 90 117 95 117 95 ApprovalMendocino 60
Page 15 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles95490 Physical Medicine and
RehabilitationPediatric 90 117 95 117 95 ApprovalMendocino 60
95494 Hospital N/A 30 26 24 26 24 ApprovalMendocino 15
95494 PCP Adult 30 14 14 14 14 ApprovalMendocino 10
95494 PCP Pediatric 30 14 14 14 14 ApprovalMendocino 10
95585 ENT/Otolaryngology Adult 90 105 86 105 86 ApprovalMendocino 60
95585 ENT/Otolaryngology Pediatric 90 105 86 105 86 ApprovalMendocino 60
95585 Hospital N/A 30 88 68 88 68 ApprovalMendocino 15
95585 PCP Adult 30 23 22 23 22 ApprovalMendocino 10
95585 PCP Pediatric 30 23 22 23 22 ApprovalMendocino 10
95585 Physical Medicine and Rehabilitation
Adult 90 144 116 144 116 ApprovalMendocino 60
95585 Physical Medicine and Rehabilitation
Pediatric 90 144 116 144 116 ApprovalMendocino 60
95587 ENT/Otolaryngology Adult 90 113 93 113 93 ApprovalMendocino 60
95587 ENT/Otolaryngology Pediatric 90 113 93 113 93 ApprovalMendocino 60
95587 Hospital N/A 30 81 59 81 59 ApprovalMendocino 15
95587 PCP Adult 30 79 58 79 58 ApprovalMendocino 10
95587 PCP Pediatric 30 79 58 79 58 ApprovalMendocino 10
95587 Physical Medicine and Rehabilitation
Adult 90 130 109 130 109 ApprovalMendocino 60
95587 Physical Medicine and Rehabilitation
Pediatric 90 146 104 146 104 ApprovalMendocino 60
95589 Hospital N/A 30 75 33 75 33 ApprovalMendocino 15
95589 PCP Adult 30 90 53 90 53 ApprovalMendocino 10
95589 PCP Pediatric 30 87 42 87 42 ApprovalMendocino 10
96006 ENT/Otolaryngology Adult 90 0 0 120 114 ApprovalModoc 60
Page 16 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96006 ENT/Otolaryngology Pediatric 90 121 108 121 108 ApprovalModoc 60
96006 Hematology Adult 90 151 121 151 121 ApprovalModoc 60
96006 Hematology Pediatric 90 151 121 151 121 ApprovalModoc 60
96006 Hospital N/A 30 40 37 40 37 ApprovalModoc 15
96006 Oncology Adult 90 151 121 151 121 ApprovalModoc 60
96006 Oncology Pediatric 90 151 121 151 121 ApprovalModoc 60
96006 PCP Adult 30 57 48 57 48 ApprovalModoc 10
96006 PCP Pediatric 30 57 48 57 48 ApprovalModoc 10
96006 Physical Medicine and Rehabilitation
Adult 90 101 93 101 93 ApprovalModoc 60
96006 Physical Medicine and Rehabilitation
Pediatric 90 101 93 101 93 ApprovalModoc 60
96015 ENT/Otolaryngology Adult 90 213 154 213 154 ApprovalModoc 60
96015 ENT/Otolaryngology Pediatric 90 213 154 213 154 ApprovalModoc 60
96015 Hematology Adult 90 205 153 205 153 ApprovalModoc 60
96015 Hematology Pediatric 90 205 153 205 153 ApprovalModoc 60
96015 Hospital N/A 30 51 47 51 47 ApprovalModoc 15
96015 Oncology Adult 90 205 153 205 153 ApprovalModoc 60
96015 Oncology Pediatric 90 205 153 205 153 ApprovalModoc 60
96015 PCP Adult 30 33 31 33 31 ApprovalModoc 10
96015 PCP Pediatric 30 33 31 33 31 ApprovalModoc 10
96015 Physical Medicine and Rehabilitation
Adult 90 185 147 185 147 ApprovalModoc 60
96015 Physical Medicine and Rehabilitation
Pediatric 90 204 153 204 153 ApprovalModoc 60
96056 ENT/Otolaryngology Adult 90 171 129 171 129 ApprovalModoc 60
Page 17 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96056 ENT/Otolaryngology Pediatric 90 171 129 171 129 ApprovalModoc 60
96056 Hematology Adult 90 131 127 131 127 ApprovalModoc 60
96056 Hematology Pediatric 90 131 127 131 127 ApprovalModoc 60
96056 Hospital N/A 30 97 91 97 91 ApprovalModoc 15
96056 Oncology Adult 90 131 127 131 127 ApprovalModoc 60
96056 Oncology Pediatric 90 131 127 131 127 ApprovalModoc 60
96056 PCP Adult 30 91 79 91 79 ApprovalModoc 10
96056 PCP Pediatric 30 91 79 91 79 ApprovalModoc 10
96056 Physical Medicine and Rehabilitation
Adult 90 158 127 158 127 ApprovalModoc 60
96056 Physical Medicine and Rehabilitation
Pediatric 90 158 127 158 127 ApprovalModoc 60
96101 ENT/Otolaryngology Adult 90 194 167 194 167 ApprovalModoc 60
96101 ENT/Otolaryngology Pediatric 90 195 169 195 169 ApprovalModoc 60
96101 Hematology Adult 90 191 168 191 168 ApprovalModoc 60
96101 Hematology Pediatric 90 190 168 190 168 ApprovalModoc 60
96101 Oncology Adult 90 183 162 183 162 ApprovalModoc 60
96101 Oncology Pediatric 90 183 162 183 162 ApprovalModoc 60
96101 Orthopedic Surgery Adult 90 102 97 103 97 ApprovalModoc 60
96101 Orthopedic Surgery Pediatric 90 102 97 102 97 ApprovalModoc 60
96101 PCP Adult 30 71 48 71 48 ApprovalModoc 10
96101 PCP Pediatric 30 71 48 71 48 ApprovalModoc 10
96101 Physical Medicine and Rehabilitation
Adult 90 203 174 203 174 ApprovalModoc 60
96101 Physical Medicine and Rehabilitation
Pediatric 90 168 162 168 162 ApprovalModoc 60
Page 18 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96104 ENT/Otolaryngology Adult 90 214 182 214 182 ApprovalModoc 60
96104 ENT/Otolaryngology Pediatric 90 214 182 214 182 ApprovalModoc 60
96104 Hematology Adult 90 250 189 250 189 ApprovalModoc 60
96104 Hematology Pediatric 90 250 189 250 189 ApprovalModoc 60
96104 Hospital N/A 30 28 27 28 27 ApprovalModoc 15
96104 Oncology Adult 90 251 189 251 189 ApprovalModoc 60
96104 Oncology Pediatric 90 215 193 215 193 ApprovalModoc 60
96104 Orthopedic Surgery Adult 90 144 120 144 120 ApprovalModoc 60
96104 Orthopedic Surgery Pediatric 90 144 120 144 120 ApprovalModoc 60
96104 PCP Adult 30 72 35 72 35 ApprovalModoc 10
96104 PCP Pediatric 30 28 27 28 27 ApprovalModoc 10
96104 Physical Medicine and Rehabilitation
Adult 90 289 201 289 201 ApprovalModoc 60
96104 Physical Medicine and Rehabilitation
Pediatric 90 289 201 289 201 ApprovalModoc 60
96108 ENT/Otolaryngology Adult 90 271 198 271 198 ApprovalModoc 60
96108 ENT/Otolaryngology Pediatric 90 270 198 270 198 ApprovalModoc 60
96108 General Surgery Adult 90 66 62 66 62 ApprovalModoc 60
96108 General Surgery Pediatric 90 66 62 66 62 ApprovalModoc 60
96108 Hematology Adult 90 266 196 266 196 ApprovalModoc 60
96108 Hematology Pediatric 90 266 196 266 196 ApprovalModoc 60
96108 Hospital N/A 30 67 62 67 52 ApprovalModoc 15
96108 OB/GYN N/A 90 0 0 113 79 ApprovalModoc 60
96108 Oncology Adult 90 266 196 266 196 ApprovalModoc 60
96108 Oncology Pediatric 90 266 196 266 196 ApprovalModoc 60
Page 19 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96108 Orthopedic Surgery Adult 90 168 128 168 128 ApprovalModoc 60
96108 Orthopedic Surgery Pediatric 90 168 128 168 128 ApprovalModoc 60
96108 PCP Adult 30 76 53 76 53 ApprovalModoc 10
96108 PCP Pediatric 30 77 53 77 53 ApprovalModoc 10
96108 Physical Medicine and Rehabilitation
Adult 90 254 196 254 196 ApprovalModoc 60
96108 Physical Medicine and Rehabilitation
Pediatric 90 254 196 254 196 ApprovalModoc 60
96112 ENT/Otolaryngology Adult 90 281 218 281 218 ApprovalModoc 60
96112 ENT/Otolaryngology Pediatric 90 328 218 328 218 ApprovalModoc 60
96112 Hematology Adult 90 273 198 273 225 ApprovalModoc 60
96112 Hematology Pediatric 90 273 198 304 225 ApprovalModoc 60
96112 Hospital N/A 30 36 33 36 33 ApprovalModoc 15
96112 Oncology Adult 90 273 198 304 225 ApprovalModoc 60
96112 Oncology Pediatric 90 273 198 304 225 ApprovalModoc 60
96112 Orthopedic Surgery Adult 90 166 141 166 141 ApprovalModoc 60
96112 Orthopedic Surgery Pediatric 90 166 141 166 141 ApprovalModoc 60
96112 PCP Adult 30 36 33 36 33 ApprovalModoc 10
96112 PCP Pediatric 30 36 33 36 33 ApprovalModoc 10
96112 Physical Medicine and Rehabilitation
Adult 90 270 196 302 225 ApprovalModoc 60
96112 Physical Medicine and Rehabilitation
Pediatric 90 246 209 246 209 ApprovalModoc 60
96115 ENT/Otolaryngology Adult 90 242 208 242 208 ApprovalModoc 60
96115 ENT/Otolaryngology Pediatric 90 242 208 242 208 ApprovalModoc 60
96115 Hematology Adult 90 245 203 245 203 ApprovalModoc 60
Page 20 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96115 Hematology Pediatric 90 245 203 245 203 ApprovalModoc 60
96115 Hospital N/A 30 26 25 26 25 ApprovalModoc 15
96115 Oncology Adult 90 245 203 245 203 ApprovalModoc 60
96115 Oncology Pediatric 90 245 203 245 203 ApprovalModoc 60
96115 Orthopedic Surgery Adult 90 160 131 160 131 ApprovalModoc 60
96115 Orthopedic Surgery Pediatric 90 160 131 160 131 ApprovalModoc 60
96115 PCP Adult 30 26 25 26 25 ApprovalModoc 10
96115 PCP Pediatric 30 26 25 26 25 ApprovalModoc 10
96115 Physical Medicine and Rehabilitation
Adult 90 244 198 244 198 ApprovalModoc 60
96115 Physical Medicine and Rehabilitation
Pediatric 90 244 198 244 198 ApprovalModoc 60
96134 Cardiology/Interventional Cardiology
Adult 90 73 68 73 68 ApprovalModoc 60
96134 Cardiology/Interventional Cardiology
Pediatric 90 73 68 73 68 ApprovalModoc 60
96134 Dermatology Adult 90 73 68 73 68 ApprovalModoc 60
96134 Dermatology Pediatric 90 73 68 73 68 ApprovalModoc 60
96134 Endocrinology Adult 90 73 68 73 68 ApprovalModoc 60
96134 Endocrinology Pediatric 90 73 68 73 68 ApprovalModoc 60
96134 ENT/Otolaryngology Adult 90 235 196 235 196 ApprovalModoc 60
96134 ENT/Otolaryngology Pediatric 90 232 196 232 196 ApprovalModoc 60
96134 Gastroenterology Adult 90 73 68 73 68 ApprovalModoc 60
96134 Gastroenterology Pediatric 90 73 68 73 68 ApprovalModoc 60
96134 General Surgery Adult 90 70 65 70 65 ApprovalModoc 60
96134 General Surgery Pediatric 90 70 65 70 65 ApprovalModoc 60
Page 21 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96134 Hematology Adult 90 236 196 236 196 ApprovalModoc 60
96134 Hematology Pediatric 90 236 196 236 196 ApprovalModoc 60
96134 HIV/AIDS Specialists/Infectious Diseases
Adult 90 73 68 73 68 ApprovalModoc 60
96134 HIV/AIDS Specialists/Infectious Diseases
Pediatric 90 73 68 73 68 ApprovalModoc 60
96134 Hospital N/A 30 74 68 74 68 ApprovalModoc 15
96134 Nephrology Adult 90 73 68 73 68 ApprovalModoc 60
96134 Nephrology Pediatric 90 73 68 73 68 ApprovalModoc 60
96134 Neurology Adult 90 73 68 73 68 ApprovalModoc 60
96134 Neurology Pediatric 90 73 68 73 68 ApprovalModoc 60
96134 OB/GYN N/A 90 73 68 73 68 ApprovalModoc 60
96134 Oncology Adult 90 242 196 242 196 ApprovalModoc 60
96134 Oncology Pediatric 90 181 162 235 195 ApprovalModoc 60
96134 Ophthalmology Adult 90 72 67 72 67 ApprovalModoc 60
96134 Ophthalmology Pediatric 90 72 67 72 67 ApprovalModoc 60
96134 Orthopedic Surgery Adult 90 155 108 155 108 ApprovalModoc 60
96134 Orthopedic Surgery Pediatric 90 155 108 155 108 ApprovalModoc 60
96134 PCP Adult 30 61 56 61 56 ApprovalModoc 10
96134 PCP Pediatric 30 61 56 61 56 ApprovalModoc 10
96134 Physical Medicine and Rehabilitation
Adult 90 200 163 230 195 ApprovalModoc 60
96134 Physical Medicine and Rehabilitation
Pediatric 90 181 162 231 195 ApprovalModoc 60
96134 Pulmonology Adult 90 73 68 73 68 ApprovalModoc 60
Page 22 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96134 Pulmonology Pediatric 90 73 68 73 68 ApprovalModoc 60
94558 Hospital N/A 30 78 62 78 62 ApprovalNapa 15
94558 PCP Adult 30 105 63 105 63 ApprovalNapa 10
94558 PCP Pediatric 30 121 77 121 77 ApprovalNapa 10
94567 Hospital N/A 30 17 17 17 17 ApprovalNapa 15
94567 PCP Adult 30 102 47 102 47 ApprovalNapa 10
94567 PCP Pediatric 30 102 47 102 47 ApprovalNapa 10
94574 PCP Adult 30 14 14 14 14 ApprovalNapa 10
94574 PCP Pediatric 30 14 14 14 14 ApprovalNapa 10
96003 Hospital N/A 30 18 17 18 17 ApprovalShasta 15
96007 Hospital N/A 30 21 20 21 20 ApprovalShasta 15
96008 Hospital N/A 30 38 34 38 34 ApprovalShasta 15
96008 PCP Adult 30 15 15 15 15 ApprovalShasta 10
96008 PCP Pediatric 30 16 15 16 15 ApprovalShasta 10
96013 Hospital N/A 30 25 24 25 24 ApprovalShasta 15
96013 PCP Adult 30 51 36 51 36 ApprovalShasta 10
96013 PCP Pediatric 30 51 36 51 36 ApprovalShasta 10
96016 PCP Adult 30 15 15 15 15 ApprovalShasta 10
96016 PCP Pediatric 30 15 15 15 15 ApprovalShasta 10
96017 Hospital N/A 30 21 21 21 21 ApprovalShasta 15
96017 PCP Adult 30 21 20 21 20 ApprovalShasta 10
96017 PCP Pediatric 30 17 17 17 17 ApprovalShasta 10
96022 Hospital N/A 30 20 20 20 20 ApprovalShasta 15
Page 23 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96022 PCP Adult 30 57 43 57 43 ApprovalShasta 10
96022 PCP Pediatric 30 50 43 50 43 ApprovalShasta 10
96028 ENT/Otolaryngology Adult 90 75 70 75 70 ApprovalShasta 60
96028 ENT/Otolaryngology Pediatric 90 75 70 75 70 ApprovalShasta 60
96028 Hematology Adult 90 76 71 76 71 ApprovalShasta 60
96028 Hematology Pediatric 90 76 71 76 71 ApprovalShasta 60
96028 Hospital N/A 30 21 21 21 21 ApprovalShasta 15
96028 Oncology Adult 90 76 71 76 71 ApprovalShasta 60
96028 Oncology Pediatric 90 76 71 76 71 ApprovalShasta 60
96028 PCP Adult 30 21 20 21 20 ApprovalShasta 10
96028 PCP Pediatric 30 21 20 21 20 ApprovalShasta 10
96028 Physical Medicine and Rehabilitation
Adult 90 75 70 75 70 ApprovalShasta 60
96028 Physical Medicine and Rehabilitation
Pediatric 90 75 70 75 70 ApprovalShasta 60
96033 Hospital N/A 30 25 24 25 24 ApprovalShasta 15
96033 PCP Adult 30 25 24 25 24 ApprovalShasta 10
96033 PCP Pediatric 30 25 24 25 24 ApprovalShasta 10
96040 Hematology Adult 90 69 63 69 63 ApprovalShasta 60
96040 Hematology Pediatric 90 69 63 69 63 ApprovalShasta 60
96040 Hospital N/A 30 26 25 26 25 ApprovalShasta 15
96040 Oncology Adult 90 69 63 69 63 ApprovalShasta 60
96040 Oncology Pediatric 90 69 63 69 63 ApprovalShasta 60
96040 Ophthalmology Adult 90 68 63 68 63 ApprovalShasta 60
96040 Ophthalmology Pediatric 90 68 63 68 63 ApprovalShasta 60
Page 24 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96040 PCP Adult 30 27 26 27 26 ApprovalShasta 10
96040 PCP Pediatric 30 27 26 27 26 ApprovalShasta 10
96040 Physical Medicine and Rehabilitation
Adult 90 68 63 68 63 ApprovalShasta 60
96040 Physical Medicine and Rehabilitation
Pediatric 90 68 63 68 63 ApprovalShasta 60
96047 Hospital N/A 30 115 63 115 63 ApprovalShasta 15
96047 PCP Adult 30 107 58 107 58 ApprovalShasta 10
96047 PCP Pediatric 30 107 58 107 58 ApprovalShasta 10
96051 Hospital N/A 30 94 66 94 66 ApprovalShasta 15
96051 PCP Adult 30 90 64 90 64 ApprovalShasta 10
96051 PCP Pediatric 30 82 57 82 57 ApprovalShasta 10
96056 ENT/Otolaryngology Adult 90 171 129 171 129 ApprovalShasta 60
96056 ENT/Otolaryngology Pediatric 90 171 129 171 129 ApprovalShasta 60
96056 Hematology Adult 90 130 127 130 127 ApprovalShasta 60
96056 Hematology Pediatric 90 130 127 130 127 ApprovalShasta 60
96056 Hospital N/A 30 100 91 100 91 ApprovalShasta 15
96056 Oncology Adult 90 130 127 130 127 ApprovalShasta 60
96056 Oncology Pediatric 90 130 127 130 127 ApprovalShasta 60
96056 PCP Adult 30 91 79 91 79 ApprovalShasta 10
96056 PCP Pediatric 30 91 79 91 79 ApprovalShasta 10
96056 Physical Medicine and Rehabilitation
Adult 90 158 127 158 127 ApprovalShasta 60
96056 Physical Medicine and Rehabilitation
Pediatric 90 158 127 158 127 ApprovalShasta 60
96059 Hospital N/A 30 43 40 43 40 ApprovalShasta 15
Page 25 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96059 PCP Adult 30 12 12 12 12 ApprovalShasta 10
96059 PCP Pediatric 30 12 12 12 12 ApprovalShasta 10
96062 Hospital N/A 30 27 26 27 26 ApprovalShasta 15
96062 PCP Adult 30 14 14 14 14 ApprovalShasta 10
96062 PCP Pediatric 30 16 16 16 16 ApprovalShasta 10
96065 ENT/Otolaryngology Adult 90 131 94 131 94 ApprovalShasta 60
96065 ENT/Otolaryngology Pediatric 90 131 94 131 94 ApprovalShasta 60
96065 Hematology Adult 90 130 94 130 94 ApprovalShasta 60
96065 Hematology Pediatric 90 130 94 130 94 ApprovalShasta 60
96065 Hospital N/A 30 107 91 107 91 ApprovalShasta 15
96065 Oncology Adult 90 131 94 131 94 ApprovalShasta 60
96065 Oncology Pediatric 90 131 94 131 94 ApprovalShasta 60
96065 PCP Adult 30 167 66 167 66 ApprovalShasta 10
96065 PCP Pediatric 30 125 85 125 85 ApprovalShasta 10
96065 Physical Medicine and Rehabilitation
Adult 90 134 93 134 93 ApprovalShasta 60
96065 Physical Medicine and Rehabilitation
Pediatric 90 134 93 134 93 ApprovalShasta 60
96069 Hospital N/A 30 38 35 38 35 ApprovalShasta 15
96069 PCP Adult 30 15 15 15 15 ApprovalShasta 10
96069 PCP Pediatric 30 76 44 76 44 ApprovalShasta 10
96071 Hospital N/A 30 80 71 80 71 ApprovalShasta 15
96071 PCP Adult 30 34 31 34 31 ApprovalShasta 10
96071 PCP Pediatric 30 34 31 34 31 ApprovalShasta 10
96076 Hospital N/A 30 126 70 126 70 ApprovalShasta 15
Page 26 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96076 PCP Adult 30 29 28 29 28 ApprovalShasta 10
96076 PCP Pediatric 30 29 28 29 28 ApprovalShasta 10
96088 Hospital N/A 30 43 40 43 40 ApprovalShasta 15
96088 PCP Adult 30 14 14 14 14 ApprovalShasta 10
96088 PCP Pediatric 30 14 14 14 14 ApprovalShasta 10
96096 Hospital N/A 30 151 61 151 61 ApprovalShasta 15
96096 PCP Adult 30 161 61 161 61 ApprovalShasta 10
96096 PCP Pediatric 30 160 61 160 61 ApprovalShasta 10
95568 ENT/Otolaryngology Adult 90 224 146 244 196 ApprovalSiskiyou 60
95568 ENT/Otolaryngology Pediatric 90 224 146 244 196 ApprovalSiskiyou 60
95568 Hematology Adult 90 191 100 283 141 ApprovalSiskiyou 60
95568 Hematology Pediatric 90 191 100 283 141 ApprovalSiskiyou 60
95568 Hospital N/A 30 61 56 61 56 ApprovalSiskiyou 15
95568 Oncology Adult 90 191 100 283 141 ApprovalSiskiyou 60
95568 Oncology Pediatric 90 191 100 283 141 ApprovalSiskiyou 60
95568 PCP Adult 30 104 61 104 61 ApprovalSiskiyou 10
95568 PCP Pediatric 30 104 61 14 61 ApprovalSiskiyou 10
95568 Physical Medicine and Rehabilitation
Adult 90 191 100 289 143 ApprovalSiskiyou 60
95568 Physical Medicine and Rehabilitation
Pediatric 90 191 100 283 141 ApprovalSiskiyou 60
96014 ENT/Otolaryngology Adult 90 124 107 124 107 ApprovalSiskiyou 60
96014 ENT/Otolaryngology Pediatric 90 124 107 124 107 ApprovalSiskiyou 60
96014 Hematology Adult 90 168 113 168 113 ApprovalSiskiyou 60
96014 Hematology Pediatric 90 168 113 168 113 ApprovalSiskiyou 60
Page 27 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96014 Hospital N/A 30 36 34 36 34 ApprovalSiskiyou 15
96014 Oncology Adult 90 143 108 143 108 ApprovalSiskiyou 60
96014 Oncology Pediatric 90 143 108 143 108 ApprovalSiskiyou 60
96014 PCP Adult 30 25 24 25 24 ApprovalSiskiyou 10
96014 PCP Pediatric 30 25 24 25 24 ApprovalSiskiyou 10
96014 Physical Medicine and Rehabilitation
Adult 90 148 104 148 104 ApprovalSiskiyou 60
96014 Physical Medicine and Rehabilitation
Pediatric 90 148 104 148 104 ApprovalSiskiyou 60
96023 ENT/Otolaryngology Adult 90 138 157 138 157 ApprovalSiskiyou 60
96023 ENT/Otolaryngology Pediatric 90 149 128 149 128 ApprovalSiskiyou 60
96023 Hematology Adult 90 192 157 192 157 ApprovalSiskiyou 60
96023 Hematology Pediatric 90 199 157 199 157 ApprovalSiskiyou 60
96023 Hospital N/A 30 148 95 148 95 ApprovalSiskiyou 15
96023 Oncology Adult 90 140 131 140 131 ApprovalSiskiyou 60
96023 Oncology Pediatric 90 140 131 140 131 ApprovalSiskiyou 60
96023 PCP Adult 30 24 23 24 23 ApprovalSiskiyou 10
96023 PCP Pediatric 30 24 23 24 23 ApprovalSiskiyou 10
96023 Physical Medicine and Rehabilitation
Adult 90 113 104 113 104 ApprovalSiskiyou 60
96023 Physical Medicine and Rehabilitation
Pediatric 90 113 104 113 104 ApprovalSiskiyou 60
96027 ENT/Otolaryngology Adult 90 180 134 180 134 ApprovalSiskiyou 60
96027 ENT/Otolaryngology Pediatric 90 180 134 180 134 ApprovalSiskiyou 60
96027 Hematology Adult 90 129 117 129 117 ApprovalSiskiyou 60
96027 Hematology Pediatric 90 129 117 129 117 ApprovalSiskiyou 60
Page 28 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96027 Hospital N/A 30 47 44 47 44 ApprovalSiskiyou 15
96027 Oncology Adult 90 129 117 129 117 ApprovalSiskiyou 60
96027 Oncology Pediatric 90 129 117 129 117 ApprovalSiskiyou 60
96027 PCP Adult 30 25 24 25 24 ApprovalSiskiyou 10
96027 PCP Pediatric 30 25 24 25 24 ApprovalSiskiyou 10
96027 Physical Medicine and Rehabilitation
Adult 90 232 145 232 145 ApprovalSiskiyou 60
96027 Physical Medicine and Rehabilitation
Pediatric 90 232 145 232 145 ApprovalSiskiyou 60
96031 ENT/Otolaryngology Adult 90 200 150 200 150 ApprovalSiskiyou 60
96031 ENT/Otolaryngology Pediatric 90 219 158 219 158 ApprovalSiskiyou 60
96031 Hematology Adult 90 288 188 221 155 ApprovalSiskiyou 60
96031 Hematology Pediatric 90 285 187 221 155 ApprovalSiskiyou 60
96031 Hospital N/A 30 187 126 187 126 ApprovalSiskiyou 15
96031 Oncology Adult 90 285 187 285 158 ApprovalSiskiyou 60
96031 Oncology Pediatric 90 285 187 221 155 ApprovalSiskiyou 60
96031 PCP Adult 30 135 94 135 94 ApprovalSiskiyou 10
96031 PCP Pediatric 30 135 94 135 94 ApprovalSiskiyou 10
96031 Physical Medicine and Rehabilitation
Adult 90 221 159 221 159 ApprovalSiskiyou 60
96031 Physical Medicine and Rehabilitation
Pediatric 90 221 159 221 159 ApprovalSiskiyou 60
96032 ENT/Otolaryngology Adult 90 178 147 178 147 ApprovalSiskiyou 60
96032 ENT/Otolaryngology Pediatric 90 147 141 147 141 ApprovalSiskiyou 60
96032 Hematology Adult 90 151 142 151 142 ApprovalSiskiyou 60
96032 Hematology Pediatric 90 149 141 149 141 ApprovalSiskiyou 60
Page 29 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96032 Hospital N/A 30 79 55 79 55 ApprovalSiskiyou 15
96032 Oncology Adult 90 149 141 149 141 ApprovalSiskiyou 60
96032 Oncology Pediatric 90 149 141 149 141 ApprovalSiskiyou 60
96032 PCP Adult 30 72 44 72 44 ApprovalSiskiyou 10
96032 PCP Pediatric 30 75 45 75 45 ApprovalSiskiyou 10
96032 Physical Medicine and Rehabilitation
Adult 90 147 140 147 140 ApprovalSiskiyou 60
96032 Physical Medicine and Rehabilitation
Pediatric 90 147 140 147 140 ApprovalSiskiyou 60
96034 ENT/Otolaryngology Adult 90 249 196 105 91 ApprovalSiskiyou 60
96034 ENT/Otolaryngology Pediatric 90 159 109 159 109 ApprovalSiskiyou 60
96034 Hematology Adult 90 163 110 163 110 ApprovalSiskiyou 60
96034 Hematology Pediatric 90 163 110 163 110 ApprovalSiskiyou 60
96034 Hospital N/A 30 26 25 26 25 ApprovalSiskiyou 15
96034 Oncology Adult 90 163 110 163 110 ApprovalSiskiyou 60
96034 Oncology Pediatric 90 163 110 163 110 ApprovalSiskiyou 60
96034 PCP Adult 30 22 22 22 22 ApprovalSiskiyou 10
96034 PCP Pediatric 30 22 22 22 22 ApprovalSiskiyou 10
96034 Physical Medicine and Rehabilitation
Adult 90 78 72 78 72 ApprovalSiskiyou 60
96034 Physical Medicine and Rehabilitation
Pediatric 90 78 72 78 72 ApprovalSiskiyou 60
96038 ENT/Otolaryngology Adult 90 82 76 82 76 ApprovalSiskiyou 60
96038 ENT/Otolaryngology Pediatric 90 82 76 82 76 ApprovalSiskiyou 60
96038 Hematology Adult 90 83 77 83 77 ApprovalSiskiyou 60
96038 Hematology Pediatric 90 83 77 83 77 ApprovalSiskiyou 60
Page 30 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96038 Hospital N/A 30 20 20 20 20 ApprovalSiskiyou 15
96038 Oncology Adult 90 83 77 83 77 ApprovalSiskiyou 60
96038 Oncology Pediatric 90 83 77 83 77 ApprovalSiskiyou 60
96038 PCP Adult 30 14 14 14 14 ApprovalSiskiyou 10
96038 PCP Pediatric 30 14 14 14 14 ApprovalSiskiyou 10
96038 Physical Medicine and Rehabilitation
Adult 90 82 76 82 76 ApprovalSiskiyou 60
96038 Physical Medicine and Rehabilitation
Pediatric 90 82 76 82 76 ApprovalSiskiyou 60
96039 ENT/Otolaryngology Adult 90 190 149 190 149 ApprovalSiskiyou 60
96039 ENT/Otolaryngology Pediatric 90 190 149 190 149 ApprovalSiskiyou 60
96039 Hospital N/A 30 127 95 127 95 ApprovalSiskiyou 15
96039 PCP Adult 30 21 20 21 20 ApprovalSiskiyou 10
96039 PCP Pediatric 30 21 20 21 20 ApprovalSiskiyou 10
96044 ENT/Otolaryngology Adult 90 136 129 136 129 ApprovalSiskiyou 60
96044 ENT/Otolaryngology Pediatric 90 136 129 136 129 ApprovalSiskiyou 60
96044 Hematology Adult 90 148 127 148 127 ApprovalSiskiyou 60
96044 Hematology Pediatric 90 148 127 148 127 ApprovalSiskiyou 60
96044 Hospital N/A 30 35 32 35 32 ApprovalSiskiyou 15
96044 Oncology Adult 90 148 127 148 127 ApprovalSiskiyou 60
96044 Oncology Pediatric 90 148 127 148 127 ApprovalSiskiyou 60
96044 PCP Adult 30 28 27 28 27 ApprovalSiskiyou 10
96044 PCP Pediatric 30 28 27 28 27 ApprovalSiskiyou 10
96044 Physical Medicine and Rehabilitation
Adult 90 158 133 158 133 ApprovalSiskiyou 60
Page 31 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96044 Physical Medicine and
RehabilitationPediatric 90 158 134 158 134 ApprovalSiskiyou 60
96050 ENT/Otolaryngology Adult 90 193 164 193 164 ApprovalSiskiyou 60
96050 ENT/Otolaryngology Pediatric 90 193 164 193 164 ApprovalSiskiyou 60
96050 Hematology Adult 90 192 152 192 152 ApprovalSiskiyou 60
96050 Hematology Pediatric 90 192 152 192 152 ApprovalSiskiyou 60
96050 Hospital N/A 30 91 68 91 68 ApprovalSiskiyou 15
96050 Oncology Adult 90 192 152 192 152 ApprovalSiskiyou 60
96050 Oncology Pediatric 90 192 152 192 152 ApprovalSiskiyou 60
96050 PCP Adult 30 112 64 112 64 ApprovalSiskiyou 10
96050 PCP Pediatric 30 96 64 96 64 ApprovalSiskiyou 10
96050 Physical Medicine and Rehabilitation
Adult 90 192 152 192 152 ApprovalSiskiyou 60
96050 Physical Medicine and Rehabilitation
Pediatric 90 192 152 192 152 ApprovalSiskiyou 60
96057 ENT/Otolaryngology Adult 90 169 123 169 123 ApprovalSiskiyou 60
96057 ENT/Otolaryngology Pediatric 90 169 123 169 123 ApprovalSiskiyou 60
96057 Hematology Adult 90 169 123 169 123 ApprovalSiskiyou 60
96057 Hematology Pediatric 90 169 123 169 123 ApprovalSiskiyou 60
96057 Hospital N/A 30 95 65 95 65 ApprovalSiskiyou 15
96057 Oncology Adult 90 169 123 169 123 ApprovalSiskiyou 60
96057 Oncology Pediatric 90 169 123 169 123 ApprovalSiskiyou 60
96057 PCP Adult 30 81 54 81 54 ApprovalSiskiyou 10
96057 PCP Pediatric 30 81 54 81 54 ApprovalSiskiyou 10
96057 Physical Medicine and Rehabilitation
Adult 90 153 123 153 123 ApprovalSiskiyou 60
Page 32 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96057 Physical Medicine and
RehabilitationPediatric 90 153 123 153 123 ApprovalSiskiyou 60
96058 ENT/Otolaryngology Adult 90 154 140 154 140 ApprovalSiskiyou 60
96058 ENT/Otolaryngology Pediatric 90 154 140 154 140 ApprovalSiskiyou 60
96058 Hematology Adult 90 153 141 153 141 ApprovalSiskiyou 60
96058 Hematology Pediatric 90 153 141 153 141 ApprovalSiskiyou 60
96058 Hospital N/A 30 90 81 90 81 ApprovalSiskiyou 15
96058 Oncology Adult 90 153 141 153 141 ApprovalSiskiyou 60
96058 Oncology Pediatric 90 153 141 153 141 ApprovalSiskiyou 60
96058 PCP Adult 30 29 28 29 28 ApprovalSiskiyou 10
96058 PCP Pediatric 30 29 28 29 28 ApprovalSiskiyou 10
96058 Physical Medicine and Rehabilitation
Adult 90 148 138 148 138 ApprovalSiskiyou 60
96058 Physical Medicine and Rehabilitation
Pediatric 90 148 138 148 138 ApprovalSiskiyou 60
96064 ENT/Otolaryngology Adult 90 159 129 159 129 ApprovalSiskiyou 60
96064 ENT/Otolaryngology Pediatric 90 159 129 159 129 ApprovalSiskiyou 60
96064 Hematology Adult 90 165 129 165 129 ApprovalSiskiyou 60
96064 Hematology Pediatric 90 165 129 165 129 ApprovalSiskiyou 60
96064 Hospital N/A 30 37 34 37 34 ApprovalSiskiyou 15
96064 Oncology Adult 90 166 129 166 129 ApprovalSiskiyou 60
96064 Oncology Pediatric 90 166 129 166 129 ApprovalSiskiyou 60
96064 PCP Adult 30 57 51 70 37 ApprovalSiskiyou 10
96064 PCP Pediatric 30 57 51 70 37 ApprovalSiskiyou 10
96064 Physical Medicine and Rehabilitation
Adult 90 159 128 159 128 ApprovalSiskiyou 60
Page 33 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96064 Physical Medicine and
RehabilitationPediatric 90 159 128 159 128 ApprovalSiskiyou 60
96085 ENT/Otolaryngology Adult 90 160 148 160 148 ApprovalSiskiyou 60
96085 ENT/Otolaryngology Pediatric 90 160 148 160 148 ApprovalSiskiyou 60
96085 Hematology Adult 90 207 131 207 131 ApprovalSiskiyou 60
96085 Hematology Pediatric 90 207 131 207 131 ApprovalSiskiyou 60
96085 Hospital N/A 30 24 23 24 23 ApprovalSiskiyou 15
96085 Oncology Adult 90 207 131 207 131 ApprovalSiskiyou 60
96085 Oncology Pediatric 90 207 131 207 131 ApprovalSiskiyou 60
96085 PCP Adult 30 15 15 15 15 ApprovalSiskiyou 10
96085 PCP Pediatric 30 15 15 15 15 ApprovalSiskiyou 10
96085 Physical Medicine and Rehabilitation
Adult 90 193 125 193 125 ApprovalSiskiyou 60
96085 Physical Medicine and Rehabilitation
Pediatric 90 193 125 193 125 ApprovalSiskiyou 60
96086 ENT/Otolaryngology Adult 90 427 174 427 174 ApprovalSiskiyou 60
96086 ENT/Otolaryngology Pediatric 90 427 174 427 174 ApprovalSiskiyou 60
96086 Hospital N/A 30 221 135 221 135 ApprovalSiskiyou 15
96086 PCP Adult 30 110 64 24 19 ApprovalSiskiyou 10
96086 PCP Pediatric 30 110 64 110 64 ApprovalSiskiyou 10
96094 ENT/Otolaryngology Adult 90 103 94 103 94 ApprovalSiskiyou 60
96094 ENT/Otolaryngology Pediatric 90 103 92 103 92 ApprovalSiskiyou 60
96094 Hematology Adult 90 99 94 99 94 ApprovalSiskiyou 60
96094 Hematology Pediatric 90 99 94 99 94 ApprovalSiskiyou 60
96094 Hospital N/A 30 18 17 18 17 ApprovalSiskiyou 15
Page 34 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96094 Oncology Adult 90 99 94 99 94 ApprovalSiskiyou 60
96094 Oncology Pediatric 90 94 98 94 98 ApprovalSiskiyou 60
96094 Physical Medicine and Rehabilitation
Adult 90 104 93 104 93 ApprovalSiskiyou 60
96094 Physical Medicine and Rehabilitation
Pediatric 90 97 90 97 90 ApprovalSiskiyou 60
96097 ENT/Otolaryngology Adult 90 137 126 137 126 ApprovalSiskiyou 60
96097 ENT/Otolaryngology Pediatric 90 137 126 137 126 ApprovalSiskiyou 60
96097 Hematology Adult 90 157 133 157 133 ApprovalSiskiyou 60
96097 Hematology Pediatric 90 157 133 157 133 ApprovalSiskiyou 60
96097 Oncology Adult 90 157 133 157 133 ApprovalSiskiyou 60
96097 Oncology Pediatric 90 157 133 157 133 ApprovalSiskiyou 60
96097 Physical Medicine and Rehabilitation
Adult 90 93 86 93 86 ApprovalSiskiyou 60
96097 Physical Medicine and Rehabilitation
Pediatric 90 93 86 93 86 ApprovalSiskiyou 60
96134 Cardiology/Interventional Cardiology
Adult 90 71 66 71 66 ApprovalSiskiyou 60
96134 Cardiology/Interventional Cardiology
Pediatric 90 71 66 71 66 ApprovalSiskiyou 60
96134 Dermatology Adult 90 205 90 205 90 ApprovalSiskiyou 60
96134 Dermatology Pediatric 90 205 90 205 90 ApprovalSiskiyou 60
96134 Endocrinology Adult 90 71 66 71 66 ApprovalSiskiyou 60
96134 Endocrinology Pediatric 90 71 66 71 66 ApprovalSiskiyou 60
96134 ENT/Otolaryngology Adult 90 175 172 175 172 ApprovalSiskiyou 60
96134 ENT/Otolaryngology Pediatric 90 175 172 175 172 ApprovalSiskiyou 60
96134 Gastroenterology Adult 90 156 106 156 106 ApprovalSiskiyou 60
96134 Gastroenterology Pediatric 90 156 106 156 106 ApprovalSiskiyou 60
Page 35 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96134 General Surgery Adult 90 136 111 136 111 ApprovalSiskiyou 60
96134 General Surgery Pediatric 90 136 111 136 111 ApprovalSiskiyou 60
96134 Hematology Adult 90 236 196 236 196 ApprovalSiskiyou 60
96134 Hematology Pediatric 90 236 196 236 196 ApprovalSiskiyou 60
96134 HIV/AIDS Specialists/Infectious Diseases
Adult 90 71 66 71 66 ApprovalSiskiyou 60
96134 HIV/AIDS Specialists/Infectious Diseases
Pediatric 90 71 66 71 66 ApprovalSiskiyou 60
96134 Hospital N/A 30 72 67 72 67 ApprovalSiskiyou 15
96134 Nephrology Adult 90 71 66 71 66 ApprovalSiskiyou 60
96134 Nephrology Pediatric 90 71 66 71 66 ApprovalSiskiyou 60
96134 Neurology Adult 90 71 66 71 66 ApprovalSiskiyou 60
96134 Neurology Pediatric 90 71 66 71 66 ApprovalSiskiyou 60
96134 OB/GYN N/A 90 145 112 145 112 ApprovalSiskiyou 60
96134 Oncology Adult 90 236 188 236 188 ApprovalSiskiyou 60
96134 Oncology Pediatric 90 216 172 216 172 ApprovalSiskiyou 60
96134 Ophthalmology Adult 90 72 67 72 67 ApprovalSiskiyou 60
96134 Ophthalmology Pediatric 90 72 67 72 67 ApprovalSiskiyou 60
96134 Orthopedic Surgery Adult 90 72 67 72 67 ApprovalSiskiyou 60
96134 Orthopedic Surgery Pediatric 90 72 67 72 67 ApprovalSiskiyou 60
96134 Physical Medicine and Rehabilitation
Adult 90 201 170 231 195 ApprovalSiskiyou 60
96134 Physical Medicine and Rehabilitation
Pediatric 90 201 170 231 195 ApprovalSiskiyou 60
96134 Pulmonology Adult 90 166 134 166 134 ApprovalSiskiyou 60
Page 36 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles96134 Pulmonology Pediatric 90 166 134 166 134 ApprovalSiskiyou 60
94512 PCP Adult 30 18 18 18 18 ApprovalSolano 10
94512 PCP Pediatric 30 18 17 18 17 ApprovalSolano 10
94571 Hospital N/A 30 49 36 49 36 ApprovalSolano 15
94571 PCP Adult 30 53 41 53 41 ApprovalSolano 10
94571 PCP Pediatric 30 52 43 52 43 ApprovalSolano 10
94571 Physical Medicine and Rehabilitation
Adult 60 70 47 70 47 ApprovalSolano 30
94571 Physical Medicine and Rehabilitation
Pediatric 60 70 47 70 47 ApprovalSolano 30
94585 PCP Adult 30 14 13 14 13 ApprovalSolano 10
94585 PCP Pediatric 30 14 13 14 13 ApprovalSolano 10
95690 Hospital N/A 30 26 25 26 25 ApprovalSolano 15
95690 PCP Adult 30 63 44 63 44 ApprovalSolano 10
95690 PCP Pediatric 30 63 44 63 44 ApprovalSolano 10
95690 Physical Medicine and Rehabilitation
Adult 60 66 48 66 48 ApprovalSolano 30
95690 Physical Medicine and Rehabilitation
Pediatric 60 66 48 66 48 ApprovalSolano 30
94923 Hospital N/A 30 20 19 20 19 ApprovalSonoma 15
94923 PCP Adult 30 14 14 14 14 ApprovalSonoma 10
94923 PCP Pediatric 30 14 14 14 14 ApprovalSonoma 10
95412 ENT/Otolaryngology Adult 60 90 55 90 55 ApprovalSonoma 30
95412 ENT/Otolaryngology Pediatric 60 90 55 120 79 ApprovalSonoma 30
95412 General Surgery Adult 60 125 64 125 64 ApprovalSonoma 30
95412 General Surgery Pediatric 60 125 64 125 64 ApprovalSonoma 30
Page 37 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles95412 Hematology Adult 60 121 72 121 72 ApprovalSonoma 30
95412 Hematology Pediatric 60 121 72 121 72 ApprovalSonoma 30
95412 Hospital N/A 30 119 70 119 70 ApprovalSonoma 15
95412 OB/GYN N/A 60 113 71 113 71 ApprovalSonoma 30
95412 Oncology Adult 60 121 72 121 72 ApprovalSonoma 30
95412 Oncology Pediatric 60 121 72 121 72 ApprovalSonoma 30
95412 Ophthalmology Adult 60 135 68 135 68 ApprovalSonoma 30
95412 Ophthalmology Pediatric 60 135 68 135 68 ApprovalSonoma 30
95412 Orthopedic Surgery Adult 60 97 57 97 57 ApprovalSonoma 30
95412 Orthopedic Surgery Pediatric 60 97 57 97 57 ApprovalSonoma 30
95412 PCP Adult 30 20 20 20 20 ApprovalSonoma 10
95412 PCP Pediatric 30 20 20 20 20 ApprovalSonoma 10
95412 Physical Medicine and Rehabilitation
Adult 60 135 68 135 68 ApprovalSonoma 30
95412 Physical Medicine and Rehabilitation
Pediatric 60 135 68 135 68 ApprovalSonoma 30
95421 ENT/Otolaryngology Adult 60 153 83 153 83 ApprovalSonoma 30
95421 ENT/Otolaryngology Pediatric 60 153 83 153 83 ApprovalSonoma 30
95421 Hematology Adult 60 149 80 149 80 ApprovalSonoma 30
95421 Hematology Pediatric 60 156 85 156 85 ApprovalSonoma 30
95421 Hospital N/A 30 167 79 167 79 ApprovalSonoma 15
95421 Oncology Adult 60 149 80 149 80 ApprovalSonoma 30
95421 Oncology Pediatric 60 153 83 153 83 ApprovalSonoma 30
95421 PCP Adult 30 126 57 126 57 ApprovalSonoma 10
95421 PCP Pediatric 30 126 57 126 57 ApprovalSonoma 10
Page 38 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles95421 Physical Medicine and
RehabilitationAdult 60 153 83 153 83 ApprovalSonoma 30
95421 Physical Medicine and Rehabilitation
Pediatric 60 151 83 151 83 ApprovalSonoma 30
95425 Hospital N/A 30 26 25 26 25 ApprovalSonoma 15
95441 Hematology Adult 60 87 49 144 74 ApprovalSonoma 30
95441 Hematology Pediatric 60 87 49 87 49 ApprovalSonoma 30
95441 Hospital N/A 30 27 26 27 26 ApprovalSonoma 15
95441 Oncology Adult 60 87 49 87 49 ApprovalSonoma 30
95441 Oncology Pediatric 60 87 49 87 49 ApprovalSonoma 30
95441 PCP Adult 30 13 13 13 13 ApprovalSonoma 10
95441 PCP Pediatric 30 13 13 13 13 ApprovalSonoma 10
95441 Physical Medicine and Rehabilitation
Adult 60 85 47 85 46 ApprovalSonoma 30
95441 Physical Medicine and Rehabilitation
Pediatric 60 84 47 84 47 ApprovalSonoma 30
95450 ENT/Otolaryngology Adult 60 91 61 91 61 ApprovalSonoma 30
95450 ENT/Otolaryngology Pediatric 60 97 57 97 57 ApprovalSonoma 30
95450 Hematology Adult 60 92 59 92 59 ApprovalSonoma 30
95450 Hematology Pediatric 60 91 58 91 58 ApprovalSonoma 30
95450 Hospital N/A 30 93 55 93 55 ApprovalSonoma 15
95450 Oncology Adult 60 91 57 91 57 ApprovalSonoma 30
95450 Oncology Pediatric 60 92 58 92 58 ApprovalSonoma 30
95450 PCP Adult 30 61 40 61 40 ApprovalSonoma 10
95450 PCP Pediatric 30 61 40 61 40 ApprovalSonoma 10
95450 Physical Medicine and Rehabilitation
Adult 60 106 64 106 64 ApprovalSonoma 30
Page 39 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles95450 Physical Medicine and
RehabilitationPediatric 60 106 64 106 64 ApprovalSonoma 30
95462 Hospital N/A 30 17 17 17 17 ApprovalSonoma 15
95526 Hospital N/A 30 176 83 176 83 ApprovalTrinity 15
95526 PCP Adult 30 139 75 139 75 ApprovalTrinity 10
95526 PCP Pediatric 30 139 75 139 75 ApprovalTrinity 10
95527 Hospital N/A 30 175 86 175 86 ApprovalTrinity 15
95527 PCP Adult 30 82 52 82 52 ApprovalTrinity 10
95527 PCP Pediatric 30 82 52 82 52 ApprovalTrinity 10
95552 Hospital N/A 30 149 73 149 73 ApprovalTrinity 15
95552 PCP Adult 30 26 25 26 25 ApprovalTrinity 10
95552 PCP Pediatric 30 41 20 41 20 ApprovalTrinity 10
95595 ENT/Otolaryngology Adult 90 170 94 170 94 ApprovalTrinity 60
95595 ENT/Otolaryngology Pediatric 90 170 94 170 94 ApprovalTrinity 60
95595 Hematology Adult 90 205 129 205 129 ApprovalTrinity 60
95595 Hematology Pediatric 90 226 127 226 127 ApprovalTrinity 60
95595 Hospital N/A 30 161 79 161 79 ApprovalTrinity 15
95595 Oncology Adult 90 229 127 229 127 ApprovalTrinity 60
95595 Oncology Pediatric 90 205 129 205 129 ApprovalTrinity 60
95595 Ophthalmology Adult 90 235 130 235 130 ApprovalTrinity 60
95595 Ophthalmology Pediatric 90 235 130 235 130 ApprovalTrinity 60
95595 PCP Adult 30 137 64 137 64 ApprovalTrinity 10
95595 PCP Pediatric 30 137 64 137 64 ApprovalTrinity 10
95595 Physical Medicine and Rehabilitation
Adult 90 196 115 196 115 ApprovalTrinity 60
Page 40 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles95595 Physical Medicine and
RehabilitationPediatric 90 192 114 192 114 ApprovalTrinity 60
96010 Hospital N/A 30 61 34 61 34 ApprovalTrinity 15
96010 PCP Adult 30 25 24 25 24 ApprovalTrinity 10
96010 PCP Pediatric 30 25 24 25 24 ApprovalTrinity 10
96024 Hospital N/A 30 58 49 58 49 ApprovalTrinity 15
96024 PCP Adult 30 21 20 21 20 ApprovalTrinity 10
96024 PCP Pediatric 30 21 20 21 20 ApprovalTrinity 10
96041 Hospital N/A 30 97 51 97 51 ApprovalTrinity 15
96041 PCP Adult 30 18 18 18 18 ApprovalTrinity 10
96041 PCP Pediatric 30 45 26 45 26 ApprovalTrinity 10
96048 PCP Adult 30 15 15 15 15 ApprovalTrinity 10
96048 PCP Pediatric 30 15 15 15 15 ApprovalTrinity 10
96052 Hospital N/A 30 30 28 30 28 ApprovalTrinity 15
96052 PCP Adult 30 117 55 19 17 ApprovalTrinity 10
96052 PCP Pediatric 30 117 55 19 17 ApprovalTrinity 10
96076 Hospital N/A 30 126 70 126 70 ApprovalTrinity 15
96076 PCP Adult 30 91 49 91 49 ApprovalTrinity 10
96076 PCP Pediatric 30 91 49 91 49 ApprovalTrinity 10
96091 Hospital N/A 30 163 87 60 37 ApprovalTrinity 15
96091 PCP Adult 30 96 63 57 36 ApprovalTrinity 10
96091 PCP Pediatric 30 96 63 57 36 ApprovalTrinity 10
95606 Hospital N/A 30 32 29 32 29 ApprovalYolo 15
95606 PCP Adult 30 23 22 23 22 ApprovalYolo 10
Page 41 of 42Partnership Health Plan of California2020
County Zip Code
Provider Type Pediatric, Adult, or N/A
County Size Standards
MCP Requested
Minutes Miles
DHCS RationaleDHCS Determination
Minutes MilesMinutes Miles95606 PCP Pediatric 30 25 24 25 24 ApprovalYolo 10
95607 Hospital N/A 30 37 27 37 27 ApprovalYolo 15
95607 PCP Adult 30 115 60 113 60 ApprovalYolo 10
95607 PCP Pediatric 30 115 60 115 60 ApprovalYolo 10
95612 Hospital N/A 30 23 20 23 20 ApprovalYolo 15
95612 PCP Adult 30 65 43 65 43 ApprovalYolo 10
95612 PCP Pediatric 30 65 44 65 44 ApprovalYolo 10
95615 Hospital N/A 30 25 19 25 19 ApprovalYolo 15
95615 PCP Adult 30 33 27 33 27 ApprovalYolo 10
95615 PCP Pediatric 30 33 27 33 27 ApprovalYolo 10
95627 Hospital N/A 30 30 22 30 22 ApprovalYolo 15
95637 Hospital N/A 30 47 35 47 35 ApprovalYolo 15
95637 PCP Adult 30 86 62 86 62 ApprovalYolo 10
95637 PCP Pediatric 30 25 24 25 24 ApprovalYolo 10
95645 Hospital N/A 30 21 20 21 20 ApprovalYolo 15
95645 PCP Adult 30 18 18 18 18 ApprovalYolo 10
95645 PCP Pediatric 30 18 18 18 18 ApprovalYolo 10
Page 42 of 42Partnership Health Plan of California2020
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