With this Bulletin, the Financial Services Commission of Ontario (FSCO) is releasing a new Health Claims for Auto Insurance (HCAI) December 2014 Guideline – Superintendent’s Guideline No. 04/14 (new Guideline). This new Guideline replaces the previous Health Claims for Auto Insurance July 2012 Guideline – Superintendent’s Guideline No. 02/12 (current Guideline) that was issued in June 2012.
This new Guideline applies to documents specified in the Guideline that are delivered on or after December 1, 2014, regardless of the date of the accident to which they relate.
FSCO has revised the Guideline to include new processes to address the implementation of Service Provider Licensing. Requirements for both service providers issued a licence under section 288.5(3) of the Insurance Act and unlicensed service providers are included in the new Guideline.
Some of the revisions in the new Guideline include:
Auto Insurance Standard Invoice (OCF-21) Submission Rules
The process for the submission of the Auto Insurance Standard Invoice (OCF-21) has changed, however both service providers and unlicensed service providers will continue to complete and submit the Auto Insurance Standard Invoice (OCF-21) through HCAI.
Insurers will also continue to record their adjudication decisions in HCAI for all invoice submissions from service providers and unlicensed service providers.
Service providers are required to enter, validate and submit the OCF-21 through HCAI. The insurer then can pay the service provider directly for approved goods and services.
Unlicensed service providers are required to enter and validate the OCF-21 in HCAI. FSCO anticipates that once proposed regulations are passed, unlicensed service providers will have to provide a hard copy of the HCAI-validated OCF-21 to the claimant for submission to their insurer, and seek payment directly from the claimant.
Insurers are prohibited from paying unlicensed service providers directly for listed expenses provided on or after December 1, 2014. Insurers should carefully review the date of service recorded on the OCF-21 for the listed expense to confirm whether the service provider licensing regime applies. Goods and services provided prior to December 1, 2014 are not subject to service provider licensing legislation.
Frequency of Invoicing
Under the current Guideline, service providers are restricted to submitting invoices only once a treatment plan has been completed, or once every 30 calendar days if the treatment extends beyond a month.
In response to feedback received by stakeholders, this requirement is being revised. Under the new Guideline, Service Providers can submit invoices once a treatment plan has been completed, or once per calendar month if the treatment extends beyond a month.
Attendant Care is no longer subject to the Guideline and is not specified for the purposes of SABS section 49. Therefore, OCF-21's in relation to Attendant Care should not be submitted through HCAI.
Planned HCAI System Outage
The HCAI system will be updated to support the transition to the new Guideline.
Insurers and providers should ensure that they successfully complete and submit their forms before 5 p.m. Eastern Daylight Time (EDT) on November 28, 2014, if they are to be processed under the HCAI July 2012 Guideline. The HCAI servers will be taken offline and become inaccessible at exactly 5:01 p.m. EDT on November 28, 2014. HCAI and its DEC will not accept any forms after 5 p.m. EDT on November 28, 2014. Any forms that are not processed by 5 p.m. EDT on November 28, 2014 will be deemed not to have been received by HCAI before December 1, 2014 and will therefore be processed in accordance with the new Guideline.
The updated HCAI system will become available at 8 a.m. EDT on December 1, 2014.
The new Guideline is issued pursuant to section 268.3 (1) of the Insurance Act for the purposes of the SABS.
Copies of the HCAI Guideline
The new Guideline is available on FSCO’s website at www.fsco.gov.on.ca and will be published in the November 29th 2014 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 email:
Chief Executive Officer and
Superintendent of Financial Services
November 24, 2014