How Do I Review My Submission?
When an adjuster has adjudicated your OCF, you can find it under the Adjuster Response tab. You can now review the OCF to find more details about the Adjuster’s response.
- From the Adjuster Response tab, click on the Review Form button next to the OCF you want to open. (View screenshot)
- The Summary page is automatically generated after the OCF is submitted. It provides an overview of the OCF and also displays the OCF’s message log and current state.
- In the Part 3: Plan/Invoice Details section you will see:
- Document Number: This is a system-generated number unique to the plan.
- Owner: This field displays the name of any Adjuster who is currently working on the plan.
- Approved – The Adjuster has approved all the goods and services proposed under the plan.
- Partially Approved – The Adjuster has approved only some of the goods and services proposed under the plan.
- Declined – The Adjuster has not approved any of the goods or services proposed under the plan.
- Responded – This status is only available on the OCF-23 and indicates that the Applicant (Patient) has a valid policy of insurance in force. The OCF-23 is a claim for “pre-approved” services, so the Adjuster cannot “Approve” an OCF-23.
Reviewing the Adjudicated Form
Each Tab of an adjudicated OCF contains read-only details presented in the same order as they were entered. Navigate through the plan by using the numbered tabs.
The following sections contain changes or response details from the Insurer:
Part 1: Applicant Information. The Applicant (Patient) details provided in the initial plan are linked to the Insurer claimant details. You can see both in this section.
Part 2: Auto Insurer Information.The Applicant (Patient) details provided in the initial plan are displayed.
Part 12: Proposed Goods and Services. The table has a new column – Adjuster Response – containing the Adjuster’s decision per service. If a service is declined, the reason code will display below.
Totalling: This section contains Proposed Amount Submitted next to the Approved Amount as recorded by the Adjuster.
Signature of Insurer: At the bottom of Tab, it contains Adjuster’s first and last name.
What does ‘status’ mean?
Once an OCF is adjudicated in HCAI, it is assigned a status:
Approved – the Insurer has approved all aspects of the submitted or amended document.
Partially Approved – the Insurer has approved some of the items requested on the plan or invoice. When the Facility opens the adjudicated plan/invoice, the Facility will be able to view the Adjuster’s reason code and additional details in the ‘Explanation of adjuster response’ box explaining why the decision was made, if the Adjuster has provided details.
Declined – the Insurer has declined the items requested on the plan or invoice. In these cases, the Insurer may notify the Applicant (Patient) of the decision via an OCF-9 and also will notify Applicant (Patient) of the next steps. When the Facility opens the adjudicated plan/invoice, the Facility will be able to see the reason for the Adjuster’s decision.
Responded – this response is specific to the OCF-23 and indicates that the Applicant (Patient) has a valid policy of insurance in force. This is because The OCF-23 is a claim for “pre-approved” services. For this reason, the Adjuster cannot “Approve” an OCF-23. However, any goods and services delivered to Applicant (Patient) within the MIG framework are still subject to adjudication.
What if my OCF has been declined?
Once a plan or invoice has been adjudicated, Facilities may open the plan or invoice to determine why the plan was declined or partially approved.
- Go to the Plans or Invoices global tab (depending on whether you are looking for an adjudicated plan or invoice).
- Go to the Adjuster Response tab.
- Locate the plan/invoice you want to open.
- Click on the Review Form button () at the left of the window to open the plan or invoice.
When you review the “Proposed Goods and Services” section, you will see which services were approved and which were not. (View screenshot)
For all services not approved, the Adjuster must provide an Adjuster Response code and explanation. These are summarized in the following Adjudication Reason Codes (PDF).
If you require more information about why a good or service was declined, contact the Adjuster or speak with the Applicant/Patient who will have received an explanation of benefits notice from the Insurer.
What is the Explanation of Benefits (EOB) form?
The Explanation of Benefits form (EOB), formerly known as the OCF- 9 is a statement sent to the claimant from their insurer explaining what medical treatments and/or services will be paid (or not) for on their behalf.
The EOB can be generated by HCAI once an adjuster has recorded a decision against a submitted OCF document.
The adjuster provides a printed copy of the EOB to the claimant. They can also choose to submit the EOB via HCAI, which will make it available to be viewed by the facility that submitted the OCF.
If an EOB has been sent, an icon will appear on the Adjuster Response tab in HCAI, next to the OCF type column. (View screenshot)
To view the EOB:
- Click on the Review Form button to open the OCF.
- Click on the “View EOB” button on the OCF summary tab. The EOB opens in a new window.
- To view the adjudication decision, click on tab 2 of the EOB.
- The “Medical and Rehabilitation and Other Benefits” included in Part 4 of the OCF are listed.
- The “Reason why expenses are not payable or being stopped” section includes the adjudication reason codes and the corresponding explanation for each code.
Please note: The Safety, Licensing Appeals and Standards Tribunal Ontario (SLASTO) has assumed all new applications for dispute resolution from the Financial Services Commission of Ontario. To streamline the user viewing experience on HCAI, Tab 3, which used to contain the Applicant’s Rights to Dispute, will be hidden from the web view. The new wording will be displayed on the paper or PDF versions of the EOB only.