With this Bulletin, the Financial Services Commission of Ontario (FSCO) is announcing a temporary suspension of the Health Claims for Auto Insurance Guideline (the Guideline) issued in December 2007 as Superintendent’s Guideline No. 07/07.
Health Claims for Auto Insurance Processing (HCAI), an Ontario not-for-profit corporation, has recently experienced difficulties in properly discharging its obligations as the Central Processing Agency (CPA). In order to protect the interests of consumers, providers, facilities and insurers, and to enable HCAI to focus on resolving these difficulties without undue delay, the operation of the Guideline has been temporarily suspended at HCAI’s request.
This suspension affects all documents that are referred to in the Guideline and submitted after 4:00 p.m. on March 12, 2008, and continues to be in effect until further notice.
For the duration of this suspension, documents referred to in the Guideline are not to be delivered to HCAI or HCAI’s Data Entry Centre (DEC), but directly to insurers using one of the standard delivery methods provided for in section 68(2) of the Statutory Accident Benefits Schedule – Accidents on or After November 1, 1996 (SABS).
- For the purposes of this Bulletin:
(a) a document that is delivered to HCAI by electronic means is "submitted" when it is actually received by HCAI.
(b) a document that is delivered to HCAI’s DEC, and is not subsequently rejected by the DEC on the grounds that the document is not duly completed or does not contain all information required by the SABS to be included in it, is "submitted" when it is actually received by HCAI’s DEC.
- Any document submitted to HCAI or to HCAI’s DEC in accordance with the requirements of the Guideline before 4:00 p.m. on March 12, 2008 will be processed by HCAI and the insurer to whom the document is addressed as required by the SABS and the Guideline.
- Any document submitted to HCAI or to HCAI’s DEC after 4:00 p.m. on March 12, 2008 will not be properly delivered in accordance with the SABS and will not be deemed to have been received by the insurer to whom it is addressed. Any such document submitted to HCAI’s DEC after 4:00 p.m. on March 12, 2008 will be returned to the sender by fax or courier.
- A document that is delivered to HCAI’s DEC before 4:00 p.m. on March 12, 2008, but is rejected under the circumstances described in paragraph 1 (b) above, must be resubmitted directly to the insurer to whom it is addressed, and not to HCAI or HCAI’s DEC.
The future operation of HCAI will be reviewed in consultation with insurers, providers and other stakeholders.
As noted in Superintendent’s Bulletin No. A-08/07 dated December 21, 2007, Guideline No. 07/07 sets out the requirements for delivery of the documents specified in sections 44.1 (1) and 68 (3.2) of the SABS. Specifically, the Guideline mandates the transmission of specified accident benefits claims forms between health care providers and insurers by way of a CPA, which is the agent designated to receive accident benefits claims forms on behalf of insurers. The Guideline names HCAI, an Ontario not-for-profit corporation, as the CPA.
The Guideline provides as follows:
"Temporary Suspensions Of This Guideline
In the event that the CPA becomes unable (e.g., by reason of temporary technical issues) to properly carry out its obligations to providers, facilities or insurers, the Superintendent of Financial Services may temporarily suspend the operation of this Guideline.
The Financial Services Commission of Ontario will post notice of any suspension and subsequent resumption of operation of this Guideline on its website (www.fsco.gov.on.ca).
During the period of any such suspension, the requirements of this Guideline do not apply and documents are instead to be delivered directly to insurers using one of the standard delivery methods provided for in s. 68 (2) of the SABS."
Additional information on this suspension and on transition or processing issues can be found at www.hcaiinfo.ca or by calling 1-888-HCAI123 (1-888-422-4123).
Chief Executive Officer and
Superintendent of Financial Services
March 11, 2008