The following health insurers in Hawaii have agreed to the settlement:
Hawaii Medical Services Association (HMSA)
Only HMA members have the benefit of HMA representation for the enforcement of settlement terms. HMA will report systemic issues and violations of settlement terms to the Complicance Facilitator.
To report violations, contact the Hawaii Medical Association:
Paula Arcena, Executive Director
1360 Beretania Street 2nd Floor
Honolulu, HI 96814
Phone: (808) 536-7702
Fax: (808) 528-2376
E-mail: paula_arcena@hma-assn.org
State-specific provisions of settlement:
H_ § 7.13(a) Credentialing
The Blue Plan Hawaii Medical Service Association (hereinafter as used in this Exhibit H "HMSA") is subject to the following amendment to the second sentence of § 7.13(a):
HMSA shall complete primary source verification and notify the Physician as to whether he or she is credentialed within thirty-five (35) days of receiving a Physician’s completed application to be a Participating Physician unless in spite of HMSA’s best efforts and because of a failure of a third party to provide necessary documentation, HMSA cannot obtain the necessary information to make a decision within thirty-five (35) days. The thirty-five day period shall be tolled for: 1) any time period HMSA is waiting on information from the Physician; and 2) the time period primary source verification is pending with CVS.
H __ § 7.22 Overpayment Recovery Procedures
(c) HMSA shall comply with the obligations under § 7.22 except with respect to the time limit for Overpayment recovery efforts for claims that are paid under a Plan that are later determined to be the responsibility of a workers compensation carrier. For claims that are determined to be the responsibility of a workers compensation carrier, HMSA shall have four years after the payment was received by the Physician to recover from the Physician the difference between what the Physician was paid by HMSA for the claim and the amount the claim is determined to be payable under workers compensation.
(d) HMSA will satisfy the notice requirements of § 7.22 for Medicare cross over claims and Medigap claims by providing on the Report to Provider (i) the patient’s name; (ii) claim identification number (iii) the service date; (iv) the payment amount received by Physician; and (v) a reasonably specific explanation of the change (including the procedure code, where appropriate).
H __ § 7.29(c)(ii)(F) Arbitration
(e) HMSA may require arbitration proceedings to occur in Honolulu, Hawaii. Physicians who have an office on an island other than Oahu may, at the physician’s election, participate in arbitrations by telephone or in person.
H __ § 7.30 Compliance with State Law and Applicable Government Contracts
(f) HMSA shall not be required to comply with the obligations under § 7 with respect to the QUEST program. HMSA agrees that for the QUEST program:
1. HMSA shall comply with § 7.13(b) and will not require a Participating Physician to participate in the QUEST program in order to participate in Product Networks in which such Participating Physician is compensated on a fee for service basis; and
2. HMSA shall comply with § 7.20 solely by utilizing Medicare CCI Edits in processing QUEST claims and the CCI Edits are the sole system of Edits applied to such claims.
H__HMSA – 65C Plus Program
This provision clarifies that HMSA's provision of Medicare part B services under its 65C Plus program is included within the exemption of 7.30(a) for a Blue Party's role as a carrier providing administrative services for Medicare Part B business.