Health Claims for Auto Insurance 2009 Pilot Guideline

 

Bulletin

No. A-05/09
 
Property & Casualty – Auto
[To the attention of all insurance companies
licensed to transact auto insurance in Ontario]

 

With this Bulletin, the Financial Services Commission of Ontario (FSCO) is releasing the Health Claims for Auto Insurance 2009 Pilot Guideline – Superintendent’s Guideline No. 03/09 (Pilot Guideline).  The Pilot Guideline replaces the previous Health Claims for Auto Insurance Guideline – Superintendent’s Guideline No. 07/07 that was issued in December 2007. 

 

The Pilot Guideline is being issued to facilitate a staged return of the Health Claims for Auto Insurance (HCAI) system that was temporarily suspended on March 11, 2008 by Property and Casualty – Auto Bulletin A-01/08.  If the HCAI system meets performance expectations at the end of the pilot phase, we anticipate that one or more further guidelines will be issued.  They will set out the process and timelines for introducing mandatory participation rules in a staged manner for all insurers and health care providers.

 

 

HCAI 2009 Pilot Guideline

 

In this pilot phase, the Pilot Guideline only applies to insurers and health care providers that volunteer to participate and be governed by this Pilot Guideline. Insurance companies, health care providers and facilities that have not signed up to participate in the Pilot Guideline will continue to use the standard methods for forms delivery that are set out in the Statutory Accident Benefits Schedule – Accidents on or After November 1, 1996 (SABS).

 

This Pilot 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 SABS, as amended by Regulation 533/06.  The Pilot Guideline enables 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.  In addition to receiving forms, the CPA will confirm that forms are completed and then make this information available to the insurers to whom they are addressed. The CPA also enables insurers to communicate claims approval and payment decisions to health care providers.

 

The Pilot Guideline:

 

  • Lists insurers and health care providers that are subject to the Pilot Guideline;
  • Designates Health Claims for Auto Insurance Processing, an Ontario not-for-profit corporation, as the CPA;
  • Sets out specific accident benefit claim forms that are subject to this Pilot Guideline and that must be delivered to the CPA;
  • Describes how to deliver documents to the CPA;
  • Includes rules governing attachments and when documents are considered received by the CPA;
  • 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 and the CPA.

 
HCAI Participant List

 

Health care providers or facilities that wish to submit and receive information through the CPA must first enroll with the CPA, and agree to specific terms and conditions. The terms and conditions deal with confidentiality, security, liability, access and data integrity. Appendix 1 of the Pilot Guideline provides information on how to access the HCAI Participant List, which sets out the names of insurers, health care providers and facilities that are subject to this Pilot Guideline.

 

The HCAI Participant List will be maintained by FSCO and is expected to be updated at a minimum, on the first Monday of each month (or Tuesday in the event of a holiday). The most current list is available on FSCO’s website at: www.fsco.gov.on.ca/english/insurance/auto/hcai.asp.

Paper Submissions

 

Initially, the CPA will only be able to receive documents in electronic format. It is anticipated that in the near future, the CPA will also be able to receive documents in paper format. An amended version of the Pilot Guideline, which sets out the rules that will apply to paper submissions, will be issued at that time.

Effective Date

 

This Pilot Guideline applies to participating insurers, health providers and facilities in respect of documents specified in the Pilot Guideline that are delivered on or after September 28, 2009, regardless of the date of the accident to which they relate.

Publication

 

The Pilot Guideline is expected to be published in the September 26, 2009 edition of The Ontario Gazette.

 

 

Additional HCAI Information

 

Inquiries, questions and additional information on the HCAI system (e.g., enrollment, coding, technical specifications, and educational material) can be found online at: www.hcaiinfo.ca.  If your question is not addressed by the website, you may contact HCAI by telephone or e-mail at:

 

 

Philip Howell
Chief Executive Officer and
Superintendent of Financial Services

September 17, 2009

 

Attachments:              
 


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