Health Claims for Auto Insurance September 2010 Guideline

 

Bulletin

No. A-20/10
– Auto
Property & Casualty

To the attention of all insurance companies licensed to transact
auto insurance in Ontario and all health care providers


With this Bulletin, the Financial Services Commission of Ontario (FSCO) is releasing a Health Claims for Auto Insurance September 2010 Guideline – Superintendent's Guideline No. 07/10 (new Guideline).  This new Guideline replaces the previous Health Claims for Auto Insurance 2010 Rollout Guideline – Superintendent's Guideline No. 01/10 (Rollout Guideline) that was issued in May 2010 and discussed in Property and Casualty – Auto Bulletin A-06/10.  


As noted in Auto Bulletin A-06/10, this new Guideline is being issued to reflect the implementation of the new Statutory Accident Benefits Schedule – Effective September 1, 2010 (new SABS).


New Guideline 


This new 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 49(1) and 64(7) of the new SABS.  The new Guideline mandates the transmission of certain accident benefit claim 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.  Health Claims for Auto Insurance Processing is the CPA for the purposes of the new Guideline and section 64 (7) of the new SABS.


As indicated in the new Guideline, the system is designed to enable health care facilities to enrol in Health Claims for Auto Insurance (HCAI) for the purpose of transmitting Ontario Claim Forms (OCF) 18, 21 and 23 to auto insurers.  Health care facilities may submit OCF forms to HCAI in one of two ways: either electronically (through an online web application with or without a practice management  software (PMS) interface), or in paper format. Paper submissions need to be made to HCAI's data entry centre (DEC), where the data will be transcribed, validated and submitted electronically to the insurer.  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 facilities.


The new Guideline also:


  • States that all insurers, and those health care facilities named on FSCO's website, are subject to the new Guideline.
  • Designates Health Claims for Auto Insurance Processing (HCAI Processing), an Ontario not-for-profit corporation, as the CPA.
  • Sets out specific accident benefit claim forms that are subject to this new 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 to be received by the CPA.
  • Includes rules dealing with the deemed receipt of documents.
  • Includes coding information required to complete specified forms and documents.
  • Provides other technical details regarding HCAI and the CPA.

HCAI Participant List


As of May 22, 2010, FSCO no longer maintains the HCAI Participant List for insurers, as the system became mandatory for all insurers that are licensed to transact auto insurance in Ontario, and that are administering SABS benefits claims under motor vehicle liability policies issued in Ontario. 


HCAI Participating Provider List


Health care providers or facilities that wish to submit and receive information through the CPA must first enrol 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 new Guideline provides information on how to access the HCAI Participating Provider List, which provides the names of health care providers or facilities that are subject to the new Guideline.


The HCAI Participating Provider List will be maintained by FSCO and is expected to be updated, at a minimum, on the first Monday of each month (or the next business day in the event of a holiday). The latest list is available on FSCO's website at: www.fsco.gov.on.ca/english/insurance/auto/hcai.asp.


Paper Submissions to the HCAI DEC


HCAI's DEC has been established in order to allow for the submission of paper forms to any insurer by a Participating Provider, as defined in the new Guideline. Paper versions of the forms may be delivered to HCAI's DEC – who will validate data on the forms, and then once validated, send them electronically to the insurer. Please note that a health care facility must choose which system it wants to use with HCAI, as it cannot be enrolled in both the electronic and paper submission systems simultaneously. 


As indicated in the new Guideline, any attachments to a form must be delivered directly to the insurer, and not be sent to HCAI's DEC. Any attachments that are sent to the DEC will be deemed not to have been received by the insurer, and will be destroyed, not returned.


Any documents that are submitted to HCAI's DEC must be properly completed in accordance with the directions set out in the OCF forms, and the validation rules that are attached to the new Guideline. HCAI's DEC will notify health care facilities of forms that are incomplete, or incorrectly completed, within two business days of receipt. Health care facilities are encouraged to correct any errors that are identified by the DEC in its error report, and to resubmit the form as quickly as possible.


Planned HCAI System Outage


Please note that the HCAI system has been updated to support the new SABS and the new OCF forms.  Effective September 1, 2010, the updated system will accommodate the new Treatment and Assessment Plan (OCF-18), Auto Insurance Standard Invoice (OCF-21) and Treatment Confirmation Form (OCF-23).  It will also process these forms according to the requirements of the new SABS.


Insurers and providers should ensure that they successfully complete and submit their forms before 5 p.m. Eastern Daylight Time (EDT) on August 31, 2010, if they want their forms processed by HCAI before September 1, 2010. This will enable HCAI to process the transactions by the end of the business day, as the HCAI servers will be taken offline and will become inaccessible at exactly 5 p.m. EDT on August 31, 2010.


HCAI and its DEC will not accept any forms after 5 p.m. EDT on August 31, 2010.  Any forms that are not processed by 5 p.m. EDT on August 31, 2010 will be deemed not to have been received by HCAI before September 1, 2010, and will therefore be governed by the new SABS.  


The updated HCAI system will become available at 8 a.m. EDT on September 1, 2010.  At this point, HCAI and its DEC will begin accepting the new OCF forms.


Enrolment in HCAI


Insurers and health care facilities must complete the enrolment process for HCAI before using the system.  Any forms that are delivered to HCAI prior to enrolment will not be processed. 


Please note that there are separate enrolment processes for each mode of transmission (electronic or paper). Facilities must notify HCAI if they wish to switch from one mode to another, and must complete the appropriate enrolment process.


Effective Date


The new Guideline applies to all insurers that issue auto insurance policies in Ontario, and to participating health providers and facilities in respect to documents specified in the new Guideline that are delivered on or after September 1, 2010 – regardless of the date of the accident to which they relate.


Publication


The new Guideline will be published in an upcoming edition of The Ontario Gazette. 


Additional HCAI Information


Inquiries, questions and additional information on the HCAI system (e.g., enrolment, coding, technical specifications, and educational material) can be found online at: www.hcaiinfo.ca.  


If a question is not addressed by this website, please contact HCAI Processing by telephone or e-mail:


 


Philip Howell
Chief Executive Officer and
Superintendent of Financial Services


August 18, 2010



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