Health Care Facility | Insurers | Related Initiatives  

Adjudicating the OCF-18


In the OCF-18, the information submitted by the facility displayed in Tabs 2-4 is read only and can be reviewed by clicking through the tabs or reviewing a PDF of the submitted form. A PDF of the form can be generated by clicking on the ‘Print’ button at the top of the screen. When you are ready to mark an adjudication decision on the form, approval decisions are made on Tab 5.

If you are declining a plan or a line item, you must apply a valid reason code. These reason codes provide valuable anonymized statistics for your organization and the industry.

Adjudicating the OCF-18

Click through the side menu for step-by-step guides on approving, partially approving and declining OCF-18s in HCAI.

Adjudicating the OCF-18


Approving an OCF-18

To approve the plan without any modifications:

  1. Scroll to Tab 5.
  2. Press the ‘Set Charged Costs to Approved Costs’ button. (View screenshot)
  3. The screen refreshes and the Cost, Total Count and Proposed Tax boxes are updated automatically to display the same values/selections as proposed by the facility.
  4. In Part 13, provide an answer to “Is the applicant’s or substitute decision maker’s signature waived by the insurer?” (View screenshot)
  5. Press the ‘Approve’ button.
  6. The screen will refresh and a message will confirm that the document has been approved.

Adjudicating the OCF-18


Partially Approving an OCF-18

When you want to approve some, but not all line items, you are partially approving the document.

If there are only one or a few line items to decline, you may wish to apply the reason codes individually at the line item level.

  1. Scroll to Tab 5.
  2. Press the ‘Set Charged Costs to Approved Costs’ button. (View screenshot)
  3. Scroll to the ‘Proposed Goods and Services” section and review each line item individually. If the line item is being declined, enter “0” and ensure you enter a reason code for declining that line item.
  4. If you’d like to see an updated insurer total, press the ‘Calculate’ button.
  5. In Part 13, provide an answer to “Is the applicant’s or substitute decision maker’s signature waived by the insurer?” (View screenshot)
  6. Press the ‘Partially Approve’ button.
  7. The screen will refresh and a message will confirm that the document has been partially approved.

For plans with many line items, individually reviewing line items can take a long time. If many of the declined items have the same reason code, there is a shortcut:

  1. Scroll to Tab 5.
  2. Press the ‘Set Reason Code for Declining’ button (View screenshot) and enter the desired reason code.
  3. Scroll to the ‘Proposed Goods and Services” section and, instead of zero, enter the quantity and amounts on line items you wish to approve. To update the ‘Totalling’ window, press the ‘Calculate’ button.
  4. In Part 13, provide an answer to “Is the applicant’s or substitute decision maker’s signature waived by the insurer?” (View screenshot)
  5. Press the ‘Partially Approve’ button.
  6. The screen will refresh and a message will confirm that the document has been partially approved.

Adjudicating the OCF-18


Declining an OCF-18

To decline the entire plan for the same reason:

  1. Scroll to Tab 5.
  2. Press the ‘Set Reason Code for Declining’ button (View screenshot) and enter the desired reason code.
  3. The screen will refresh and all line items in the “Proposed Goods and Services” box will be updated to zero.
  4. In Part 13, provide an answer to “Is the applicant’s or substitute decision maker’s signature waived by the insurer?” (View screenshot)
  5. Press the ‘Do Not Approve’ button.
  6. The screen will refresh and a message will confirm that the document has been declined.

If you wish to decline the entire plan with different reasons for each item:

  1. Scroll to Tab 5.
  2. Press the ‘Set Reason Code for Declining’ button (View screenshot) and the reason code that is most common for the line items.
  3. The screen will refresh and all line items in the “Proposed Goods and Services” box will be updated to zero.
  4. Scroll to the ‘Proposed Goods and Services Section and press the blue ellipsis (…) button at the end of each line item to update the reason code (View screenshot). Repeat this for each line item you wish to change.
  5. In Part 13, provide an answer to “Is the applicant’s or substitute decision maker’s signature waived by the insurer?” (View screenshot)
  6. Press the ‘Do Not Approve’ button.
  7. The screen will refresh and a message will confirm that the document has been declined.

Adjudicating the OCF-18


Jump to:

In the OCF-18, the information submitted by the facility displayed in Tabs 2-4 is read only and can be reviewed by clicking through the tabs or reviewing a PDF of the submitted form. A PDF of the form can be generated by clicking on the ‘Print’ button at the top of the screen. When you are ready to mark an adjudication decision on the form, approval decisions are made on Tab 5.

If you are declining a plan or a line item, you must apply a valid reason code. These reason codes provide valuable anonymized statistics for your organization and the industry.


Approving an OCF-18

To approve the plan without any modifications:

  1. Scroll to Tab 5.
  2. Press the ‘Set Charged Costs to Approved Costs’ button. (View screenshot)
  3. The screen refreshes and the Cost, Total Count and Proposed Tax boxes are updated automatically to display the same values/selections as proposed by the facility.
  4. In Part 13, provide an answer to “Is the applicant’s or substitute decision maker’s signature waived by the insurer?” (View screenshot)
  5. Press the ‘Approve’ button.
  6. The screen will refresh and a message will confirm that the document has been approved.

Partially Approving an OCF-18

When you want to approve some, but not all line items, you are partially approving the document.

If there are only one or a few line items to decline, you may wish to apply the reason codes individually at the line item level.

  1. Scroll to Tab 5.
  2. Press the ‘Set Charged Costs to Approved Costs’ button. (View screenshot)
  3. Scroll to the ‘Proposed Goods and Services” section and review each line item individually. If the line item is being declined, enter “0” and ensure you enter a reason code for declining that line item.
  4. If you’d like to see an updated insurer total, press the ‘Calculate’ button.
  5. In Part 13, provide an answer to “Is the applicant’s or substitute decision maker’s signature waived by the insurer?” (View screenshot)
  6. Press the ‘Partially Approve’ button.
  7. The screen will refresh and a message will confirm that the document has been partially approved.

For plans with many line items, individually reviewing line items can take a long time. If many of the declined items have the same reason code, there is a shortcut:

  1. Scroll to Tab 5.
  2. Press the ‘Set Reason Code for Declining’ button (View screenshot) and enter the desired reason code.
  3. Scroll to the ‘Proposed Goods and Services” section and, instead of zero, enter the quantity and amounts on line items you wish to approve. To update the ‘Totalling’ window, press the ‘Calculate’ button.
  4. In Part 13, provide an answer to “Is the applicant’s or substitute decision maker’s signature waived by the insurer?” (View screenshot)
  5. Press the ‘Partially Approve’ button.
  6. The screen will refresh and a message will confirm that the document has been partially approved.

Declining an OCF-18

To decline the entire plan for the same reason:

  1. Scroll to Tab 5.
  2. Press the ‘Set Reason Code for Declining’ button (View screenshot) and enter the desired reason code.
  3. The screen will refresh and all line items in the “Proposed Goods and Services” box will be updated to zero.
  4. In Part 13, provide an answer to “Is the applicant’s or substitute decision maker’s signature waived by the insurer?” (View screenshot)
  5. Press the ‘Do Not Approve’ button.
  6. The screen will refresh and a message will confirm that the document has been declined.

If you wish to decline the entire plan with different reasons for each item:

  1. Scroll to Tab 5.
  2. Press the ‘Set Reason Code for Declining’ button (View screenshot) and the reason code that is most common for the line items.
  3. The screen will refresh and all line items in the “Proposed Goods and Services” box will be updated to zero.
  4. Scroll to the ‘Proposed Goods and Services Section and press the blue ellipsis (…) button at the end of each line item to update the reason code (View screenshot). Repeat this for each line item you wish to change.
  5. In Part 13, provide an answer to “Is the applicant’s or substitute decision maker’s signature waived by the insurer?” (View screenshot)
  6. Press the ‘Do Not Approve’ button.
  7. The screen will refresh and a message will confirm that the document has been declined.
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