Service Provider Compliance Guidelines

 

Service Provider Compliance Guidelines

The following compliance rules outlined in Regulations provide information on the actions that service providers must take to make sure they are complying with the law.

 

Responding to Requests for Information

Provide Information to Insurers within 10 Business Days

If an automobile insurer requests the following information, service providers must provide the information within ten (10) business days:

  • The licence number issued to the service provider.
  • The name(s) of any regulated health professional(s), social worker(s) or any other authorized person associated with the service provider that provide goods and services in connection with listed expenses.
  • The registration number issued to a regulated health professional or to a social worker associated with the service provider.
  • The name of any regulated health professional, social worker or any other authorized person, previously associated with the service provider and the time period in which such person(s) was so authorized, within the six (6) year period before the date of the request.

Provide Information to Claimants within 10 Business Days

If a statutory accident benefit claimant requests the following information, service providers must provide the information within ten (10) business days:

  • Details of assessments and examinations performed or provided.
  • Details of reports, forms, plans, goods or services provided or delivered.
  • Invoices submitted in respect of a listed expense.
  • Any other documents giving rise to a claim for payment of a listed expense.

Note: The service provider is not required to give an individual information or documents that relate to an examination required by an automobile insurer under section 44 of the Statutory Accident Benefits Schedule (SABS). [New Window]


Submitting Forms with Accurate Information

Verify Claimant Identity

Service providers must take reasonable steps to verify the identity of any statutory accident benefit claimant that is listed on an invoice.

 

Use Only the Service Provider Authorized Licence Name and Number

OCF-21s must be submitted to automobile insurers using only the name and licence number that corresponds with the service provider licence as issued by FSCO.

 

Do Not Submit Duplicate or Frequent Documents

Service providers must take reasonable steps to make sure that duplicate versions of documents are not submitted to automobile insurers through the Health Claims for Auto Insurance (HCAI) system.

 

Invoices for a listed expense (OCF-21s) are not to be submitted more frequently than permitted under the applicable guidelines.

 

Do Not Submit Inaccurate, False or Deceptive Information

Information (i.e., forms, plans, invoices or any other documents) relating to a claim for statutory accident benefits or to a listed expense should not be submitted to an automobile insurer if there is a reason to believe:

  • It contains inaccurate, false, misleading or deceptive information.
  • The statutory accident benefit claimant was not involved in an accident for which the accident benefit claim is made.
  • The statutory accident benefit claimant did not sustain an impairment as a result of the accident.

If the service provider believes any of the above circumstances exist, the service provider must advise the insurer, within two (2) business days of forming such a belief, of the inaccurate, false, misleading or deceptive information along with the correct information.

 

Do Not Submit Invoices without Automobile Insurer Approval

OCF-21s must not be submitted without obtaining prior approval, where required under the SABS, from the insurer.

 

However, an invoice may be submitted if the automobile insurer does not give notice of their determination within the applicable time limit set out in the SABS.

 

Use Only Approved Forms

Use only the current versions of the forms approved by the Superintendent of the Financial Services Commission of Ontario (FSCO).


Maintaining Sound Business Practices

Conduct Periodic Reviews

Periodic reviews must be conducted by the service provider to ensure it is in compliance with the law and applicable guidelines, and to also ensure the reconciliation of its billings. Reviews must be conducted at least:  

  • Once every three (3) months, if the service provider was paid $50,000 or more for listed expenses by automobile insurers in the calendar year before the review.
  • Once every 12 months, if the service provider was paid less than $50,000 for listed expenses by automobile insurers in the calendar year before the review.

Maintain Registration, Enrolment and Good Standing in the HCAI System

The service provider must make sure that each of its operated facilities, branches or locations that provide goods or services in connection with statutory accident benefits is registered, enrolled, and in good standing in the Health Claims for Auto Insurance (HCAI) system, and maintains that enrolment in good standing.

 

Establish Policies and Procedures to Promote Compliance

The service provider must establish and implement appropriate written policies and procedures to make sure that the service provider or any authorized person is complying with the law.

 

Policies and procedures must also be designed to avoid the preparation or submission of false, misleading or deceptive information to the automobile insurer or any other person related to accident benefit claims or listed expenses.

 

Establish a Complaints Process

The service provider must establish a complaints process to address and resolve complaints from automobile insurers related to their business systems and practices in connection with listed expenses.

 

Implement Principal Representative Recommendations

The Principal Representative has the authority to recommend and implement changes to the business systems/practices and management of operations to ensure compliance with applicable laws and guidelines. The service provider must implement reasonable recommendations made by the Principal Representative.


Storing Records

Retain Records

All records (including assessment, examination, report, form, plan, good or service performed or provided) related to listed expenses must be retained for at least six (6) years after the date the record is created.

 

Records must be stored at an Ontario location where the service provider’s business is carried out, or at a different location in Ontario if the service provider notifies FSCO of this location.

 

Electronic records do not need to be stored at the principal place of business or the location specified by the service provider, as long as they can be retrieved within five (5) business days upon request.

 

Ensure Security and Integrity of Records

Service providers must take reasonable steps to make sure that paper and electronic records are secure and cannot be falsified.


Reporting Information to FSCO

Maintain and Monitor a Service Provider Email Address  

The email address that is provided to FSCO must be monitored regularly, and the service provider must make sure the email address is valid and current at all times.

 

Notify FSCO of Any Changes to Service Provider Information

FSCO must be notified by the service provider within five (5) business days of the following changes:

  • A change in the mailing address, email address, telephone number or fax number.
  • A change in the location of principal place of business or any facility, branch, office or location in Ontario.
  • A change in the opening, closing, acquiring, amalgamating, or transfer of any other office that is open to the public.
  • A change in a Director, Office, or Partner, as applicable.
  • A change in the identified Principal Representative.

File an Annual Information Return

Service providers must submit an Annual Information Return (AIR) to FSCO. The AIR is provided as part of the online application process and will be completed online in subsequent years. Service providers will be required to provide accurate information about business systems and practices of the service provider business, as well as information on matters of integrity in the management of business operations.