Termination of a Participating Physician Agreement

Under the provisions of the HMSA Participating Physician Agreement (Section VII) a physician or HMSA may terminate the contract. The procedures for termination are explained below.

Physician Terminates Participating Physician Agreement

A physician may terminate the contract with HMSA with or without cause. The physician is responsible for notifying members and HMSA of their decision to terminate.

Notifying Members

All physicians, including specialists and specialty groups, are required to give HMSA members at least 30 calendar days' written notice prior to terminating the Participating Physician Agreement.

Continuity of Care

Patients undergoing an active course of treatment, such as chemotherapy, after-care following inpatient hospitalization, or stabilization of medications for a chronic condition, must be informed of options for future treatment. Pregnant members in their second or third trimester should continue to receive care through the postpartum period. Please refer to Continuity of Care.

Notifying HMSA

When physicians choose to terminate their contracts with HMSA, they must give HMSA 60 calendar days' written notice. HMSA will send the physician a confirmation letter upon receiving the physician's notice of termination. This letter will provide information on claims filing and payment options related to continuity-of-care issues.

A written termination notice may be mailed or emailed to the Provider Correspondence.

Implications for Claims Filing and Payment

In cases where terminating physicians render care to patients undergoing an active course of treatment, the physician may opt to receive direct payment of HMSA's eligible charge for up to 90 calendar days. The physician agrees to accept HMSA's eligible charge as payment in full. This payment arrangement may exceed 90 days in the case of pregnant members who require continuity of care through the postpartum period.

HMSA Terminates Participating Physician Agreement

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

If the physician's license to practice medicine in the state of Hawaii has expired or been revoked, suspended, limited, or conditioned, HMSA may terminate the agreement immediately upon written notice to the physician.

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

Appealing a Termination

If a physician decides to appeal HMSA's termination of the HMSA Participating Physician 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 physician's written request for an appeal. The Appeals Committee shall consist of at least three practicing physicians, including one specialist in the field of the appealing practitioner. Any physician who was involved in the original review of the case or 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 physician may appear to present evidence or testimony before the committee. HMSA or the physician may be represented by an attorney or by another representative at the appeal of a termination.

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

Revision History