With this Bulletin, the Financial Services Commission of Ontario (FSCO) is releasing the Health Claims for Auto Insurance Guideline (the Guideline) to replace the Health Claims for Auto Insurance Rollout Guideline issued in April 2007. Also being revised are certain accident benefit forms to show what fields are mandatory.
Guideline
This Guideline is issued pursuant to section 268.3 (1) of the Insurance Act for the purposes of setting out the requirements for delivery of certain documents under sections 44.1(1) and 68(3.2) of the Statutory Accident Benefits Schedule – Accidents on or After November 1, 1996 (SABS) as amended by Regulation 533/46. The Guideline mandates the transmission of certain accident benefit claims forms between health care providers and insurers by way of a Central Processing Agency (CPA). The CPA is the agent designated to receive accident benefit claim forms on behalf of insurers. The Guideline names Health Claims for Auto Insurance Processing (HCAI), an Ontario not-for-profit corporation, as the CPA.
As of February 1, 2008, all OCF 18, 21, 22 and 23 forms can no longer be delivered by a health care provider directly to an insurer, and must instead be delivered to HCAI for processing. As indicated in the Guideline, the system is designed to enable health care providers to enroll in one of two systems for submission of these forms: either electronically, or in paper format. Paper submission of documents will need to be made to HCAI’s data entry centre (DEC) and becomes available as of January 7, 2008. In addition to receiving forms, HCAI will also confirm that forms are completed and make this information available to the specific insurers to whom they are addressed. HCAI also enables insurers to communicate claims approval and payment decisions to health care providers who submit forms electronically.
The Guideline also:
- sets out specific accident benefit claim forms that are subject to this Guideline and that must be delivered to HCAI;
- describes how to deliver documents to HCAI and its DEC;
- includes rules governing attachments and when documents are considered received by HCAI and its DEC;
- includes rules dealing with the deemed receipt of documents;
- includes coding information required to complete specified forms and documents; and
- provides other technical details regarding HCAI’s operation.
HCAI Participant List
The HCAI Participant List will no longer be maintained by FSCO after February 1, 2008 when the system becomes mandatory for all insurers, health care providers and facilities. Insurers are requested to be proactive in the transition period, and are encouraged to process forms as normal if received directly from health care providers on or before February 7, 2008. Insurers are also requested to contact and inform health care providers about the HCAI system if the applicable forms are sent directly to them.
Paper Submissions
HCAI’s DEC has been established in order to allow for the submission of paper forms to a participating insurer by a participating health care provider. Starting January 7, 2008, the paper versions of the forms may be delivered to HCAI’s DEC. Please note that a health care provider must choose which system it wants to utilize with HCAI, as it cannot be enrolled in both the electronic and paper submission systems simultaneously.
As indicated in the attached Guideline, any attachments to a form must be delivered directly to the insurer and not sent to HCAI’s DEC. Any attachments sent to the DEC will be deemed to have not been received by the insurer, and will not be returned, but will be destroyed.
Documents submitted to HCAI’s DEC must be properly completed in accordance with the directions set out in the revised OCF forms, and the validation rules that are attached to the Guideline. HCAI’s DEC will notify providers of forms that are incomplete, or incorrectly completed within two business days of receipt by the DEC. Providers are encouraged to correct the errors identified in the DEC error report and resubmit the form as quickly as possible to the DEC.
Enrolment in HCAI
Insurers and providers must complete the enrolment process for HCAI before using the system. Any forms delivered to HCAI prior to enrollment will not be processed.
Please note that there are separate enrolment processes for each mode of transmission (electric or paper). This means that providers who wish to switch from one mode to the other must notify HCAI of the fact and will be required to complete the appropriate enrolment process.
Additional HCAI Information
Additional information on the HCAI system and how to enroll with the CPA electronically or for paper submissions through the DEC can be found at: www.hcaiinfo.ca.
Effective Dates for the Guideline
This Guideline applies to all insurers, health providers and facilities in respect of documents specified in the Guideline that are delivered on or after February 1, 2008, regardless of the date of the motor vehicle accident.
In regards to the submission of paper documents, this Guideline applies to all participating insurers and health care providers who have volunteered to be a part of the rollout phase and registered for HCAI’s DEC effective January 7, 2008. For all other parties the effective date is February 1, 2008.
Revised Accident Benefit Claim Forms
To assist in facilitating paper submissions to HCAI’s DEC, Ontario Claim Forms (OCF) 18, 21, 22 and 23 have been revised to highlight which fields must be completed. There are four categories of fields on the forms. A field without an asterisk indicates that it is mandatory and must be completed; a field with one asterisk (*) indicates that a field is required if known; a field with two asterisks (**) indicates that at least one of the two adjacent fields must be completed; and, a field with three asterisks (***) indicates that a field is optional.
Effective Date of Revised Forms
Health care providers can use the revised versions of these forms effective January 7, 2008. Health care providers can also continue to use their existing stock of OCF 18, 21, 22 and 23 forms when submitted to the DEC provided that all fields are properly completed as highlighted in these revisions.
HCAI’s DEC can continue to accept the older versions of these forms up to and including July 31, 2008. Effective August 1, 2008, the revised versions of these forms will be required for use for all paper submissions to HCAI’s DEC.
Publication
The Guideline will be published in an upcoming edition of The Ontario Gazette. The Guideline is also posted on the FSCO website at www.fsco.gov.on.ca.
Bob Christie
Chief Executive Officer and
Superintendent of Financial Services
December 21, 2007
Attachments: