With this Bulletin, the Financial Services Commission of Ontario (FSCO) is releasing the Health Claims for Auto Insurance (HCAI) Rollout Guideline. A revised Professional Services Guideline and certain revised accident benefit claim forms are also being released.
HCAI Rollout Guideline
The HCAI Rollout Guideline currently applies only to participating insurers and health care providers. Companies, health care providers and facilities that have not signed up to participate in the HCAI Rollout will continue to use the standard methods of forms delivery set out in the SABS.
It is expected that by February 1, 2008, all insurers and health care providers will be required to participate in the HCAI system. At that time, an amended version of the Guideline will be issued to reflect the requirement.
The HCAI Rollout Guideline is issued pursuant to s. 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 Statutory Accident Benefits Schedule – Accidents on or After November 1, 1996 (SABS) as amended by Regulation 533/46. The HCAI Rollout 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 HCAI Rollout Guideline:
- lists insurers and health care providers that are subject to the 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 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 HCAI Rollout 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 the HCAI Rollout Guideline.
The HCAI Participant List will be maintained by FSCO and is expected to be updated at a minimum on the first Monday of the month (or Tuesday in the event of a holiday). The most current list is available on the FSCO website at www.fsco.gov.on.ca/english/insurance/auto/hcai.asp.
Initially, the CPA will only be able to receive documents in electronic form. It is anticipated that in the near future, the CPA will also be able to receive documents in paper form. An amended version of this Guideline setting out the rules that will apply to paper submissions will be issued at that time.
The HCAI Rollout Guideline applies to participating insurers, health providers and facilities in respect of documents specified in the Guideline that are delivered on or after April 2, 2007, regardless of the date of the accident to which they relate.
Revised Professional Services Guideline
The Professional Services Guideline has been revised to reflect a change in the maximum fees payable for the electronic submission and completion of the Treatment Plan (OCF-18) and the Application for Approval of an Assessment or Examination (OCF-22) to the CPA. All other fees set out in the Professional Services Guideline remain unchanged.
The Professional Services Guideline No. 06/06 continues to apply to expenses related to services rendered or forms completed from July 1, 2006 to April 1, 2007, whether they are billed before or after April 2, 2007.
The maximum hourly rates and maximums payable for the completion of certain forms set out in the revised Professional Services Guideline apply to services rendered on or after April 2, 2007, even if approved prior to April 2, 2007.
Revised Accident Benefit Claim Forms
Further to FSCO Bulletin No. A-06/06 issued on June 9, 2006, Ontario Claim Forms (OCF) 3, 5, 18, 19 and 22 have been revised to specify that a claimant’s consent to share health care information between their health care provider and the insurer’s health professional does not apply to a voluntary consultation between a health care provider and the insurer’s health professional conducting an examination (referred to in sections 24(1) 9 and 24.1 (1) 2 of the SABS). Separate express consent is required and should be made in writing. Two minor corrections have also been made to the OCF-1 and OCF-21.
Required Use of Auto Insurance Standard Invoice (OCF-21)
Effective April 2, 2007, the revised Auto Insurance Standard Invoice (OCF-21) will be the required form for all invoices of medical and rehabilitation goods and services, attendant care, assessments and examinations set out in Appendix 2 of the HCAI Rollout Guideline and submitted by providers participating in the HCAI Rollout. Previously, the standard invoice only applied to insurers who requested the Standard Invoice where an arrangement had been made to have an insurer invoiced directly.
Effective Date and Copies of Forms
The Auto Insurance Standard Invoice (OCF-21) will be effective for use on April 2, 2007. The balance of the claim forms will be effective for use on May 1, 2007. Copies of these forms are available on the FSCO website at www.fsco.gov.on.ca.
The HCAI Rollout Guideline and the Professional Services Guideline are expected to be published in the March 17, 2007, edition of The Ontario Gazette.
Additional HCAI Information
Additional information on the HCAI system and enrollment in the CPA 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 8, 2007