Termination of a Participating Provider Agreement

Under the provisions of the HMSA participating provider agreements (which include HMSA Participating Physicians Agreement, HMSA Participating Psychologists Agreement, and HMSA Participating Provider Agreement for all other behavioral healthcare providers), a behavioral healthcare provider or HMSA may terminate the contract. The procedures are explained below.

When the Provider Initiates Termination

A provider may terminate the contract with HMSA with or without cause. The provider is responsible to notify members and HMSA of his or her termination decision.

Notifying members

Providers are required to give HMSA members at least 30 calendar days' written notice prior to terminating a participating provider agreement.

Continuity of care

Patients undergoing an active course of treatment must be informed of Continuity of Care - Behavioral Health or ongoing treatment.

Notifying HMSA

When providers choose to terminate their contracts with HMSA, they must give HMSA 60 calendar days' written notice. The notice must specify which HMSA contracts the providers are seeking to terminate. Please include the reason for the termination. The written notice must be sent to:

HMSA Provider Information Unit
P.O. Box 860
Honolulu, HI  96808

HMSA will send the provider a confirmation letter upon receiving the provider's notice of termination. This letter will provide information on claims filing and payment options related to continuity-of-care issues.

Implications for claims filing and payment

In cases where terminating providers render care to patients undergoing an active course of treatment, the provider may opt to receive direct payment of HMSA's eligible charge for up to 90 calendar days or until the current course of treatment is complete, whichever is shorter. The provider agrees to accept HMSA's eligible charge as payment in full.

When HMSA Initiates Termination

HMSA may terminate a provider's agreement if the provider does not comply with the agreement provisions, including those related to Provider Credentialing Requirements. In these cases, HMSA may terminate a provider's contract for cause with 60 calendar days' written notice.

If the provider's license to practice in the state of Hawaii has expired or has been revoked, suspended, limited, or conditioned, HMSA may terminate the agreement immediately upon written notice to the provider.

Note: If you have been excluded as an eligible behavioral health care provider for federal programs, this may or may not be grounds for termination of an HMSA participating provider agreement, depending on the circumstances. Such occurrences are reviewed by HMSA's Credentialing Committee on a case-by-case basis. Providers who are barred from providing services to Medicare patients may not provide services to members of HMSA's federally funded plans (e.g., Federal Plan 87, HMSA Plan for Postal Service Employees, the Federal Employee Program, The HMSA Plan for QUEST Members and Medicaid).

Appealing a Termination

If a provider decides to appeal HMSA's termination of an HMSA participating provider agreement, the appeal must be made in writing within 60 calendar days of the receipt of HMSA's written termination notice.

HMSA will convene a review committee within 30 calendar days of receiving the provider's written request for an appeal. The review committee will consist of at least three practicing providers. Any provider who was involved in the original review of the case or any provider who has financial interest in the outcome of the case may not sit on the committee. The committee will select one of its members to act as chairperson.

The provider may appear to present evidence or testimony before the committee. HMSA or the provider may be represented by an attorney or another representative at the appeal of a termination.

The committee will either uphold or reverse the termination decision and notify the provider of its determination within five working days. If the committee determines to uphold the termination decision, the letter will give the provider information about the arbitration process. Arbitration is the final avenue of appeal.

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