Insurers - Insurer User FAQs

The User Administrator for the company that originally assigned your userID and Password is the person that you should contact to have the password re-set. When s/he re-sets your user ID, a new password will be emailed to you from the HCAI system.

How can I find out about upcoming HCAI events (online or otherwise)?

You can check the dates for these opportunities each month by going to www.hcaiinfo.ca and clicking on the Insurer home page icon. On this page you will see underlined text on the right hand side of the page stating What’s New – Events; click the text & you will be brought to the HCAI online events calendar.

Listed on the calendar are the events for the current month. Clicking on an event will provide you with info re: that event and tell you how to reserve a space for the learning opportunity.

Where can I review a copy of the FSCO Guidelines?

The guidelines can be found at the following link Health Claims for Auto Insurance (HCAI) - Financial Services Commission of Ontario.

Where can I find a copy of the HCAI USER MANUAL?

The user manual is available online via the HCAI web application. You can access it by clicking on the icon located in the top section of the screen to the left of the HCAI logo.

What is the difference between AISI Registration versus HCAI Registration?

Auto Insurance Standard Invoice (AISI) was introduced in 2003 and was the first attempt to standardize health claims data reporting for auto collision injury claims. At that time, all health providers were required to register in order to receive an AISI registration number so they could invoice insurers for health goods and/or services delivered to people injured in automobile collisions.

AISI registration numbers are in effect until Health Claims for Auto Insurance (HCAI) becomes universally used by all Ontario auto insurers and health goods and services providers.

When health care facilities start using HCAI, they will register their practice/facility/clinic with HCAI. When using HCAI to transmit forms, the AISI registration number is not required.

How will signatures from the Health Practitioners be captured in HCAI?

Each plan requires a declaration that the Health Practitioner’s signature is on file. There is an expectation that the health practitioner has signed the form and that a copy of the signed form is available upon request from the Insurer. This section is located as follows:

OCF 18 – Part 5
OCF 22 – Part 3
OCF 23 – Part 5

How will patients “sign” the OCF forms sent to HCAI?

The following OCFs require a declaration that the applicant’s signature is “on file.”

OCF 18 – Part 12
OCF 22 – Part 8
OCF 23 – Part 5

The declaration is to confirm that the claimant has reviewed the form and that a signed copy of the form is on file and available if accessible by authorized parties with appropriate releases. The patient’s electronic signature does not have to be captured nor submitted to HCAI.

When creating and submitting plans through HCAI, will health care facilities be limited or directed to do so on new claims with accident dates on or after the HCAI implementation date, or with any claim including existing claims with accident dates before the implementation of HCAI?

Once a health care facility has enrolled in the HCAI system, s/he will be instructed to complete all forms on the HCAI system with accident dates of November 1st, 1996 onwards. If the form is being completed for an Insurer enrolled in HCAI and therefore an option on the dropdown menu, the health care facility will use the <Submit> button to forward information electronically. If the Insurer is not an option they will press <Print> and mail or fax the paper forms.

Can a health care facility build an invoice without using the original plan? Can a health care facility overcharge for expenses over and above what was approved on a plan? Does HCAI do any kind of comparison or matching and is a warning issued to the adjuster or must they match the plan to the invoice?

Health care facilities can build an invoice without using the original plan in all cases. Health care facilities can bill any amount they wish. If the facility has created the invoice from the plan, the system will check to ensure the charges match. If the invoice is created separately from a plan, the system has nothing to reference it against. When the system does match the plan to the invoice, it highlights unapproved expenses and overcharges. This should not be viewed as an adjudication decision.

Are companies that are not required to submit an OCF18/OCF22 still required to submit their invoice through HCAI? For example, transportation companies, assistive device companies, translation companies…?

If an organization is registered on HCAI and is sending any of the participating forms, these forms must be transmitted using the HCAI system.

Which codes are valid in the HCAI system?

Any codes that are located in the ICD10-CA and CCI and GAP are considered “valid” codes. If a form is transmitted through HCAI, the codes on that form are all validated.

There is no hard and fast rule about which code must be used to signify which service is being coded. If you go to the Facility webpage on coding, you can scroll down to see “guidance’” (i.e., this is NOT an enforceable rule) on coding assessments.

There are no specific codes that distinguish “knee assessment” from “elbow assessment” and the CCI code 2ZZ02 (total body assessment) is valid. If an insurer would like more information re: a specific code used by a provider or health care facility, they can request more elaboration from the facility (phone call, in discussion). The insurer can also advise the facility to use the spaces on OCF forms to offer elaboration on assessment activities (see example above).

How do I turn off the pop-up blocker for HCAI?

If you are using Internet Explorer, this should work:

Go to the Tools menu.
Select Pop-up Blocker. (If this isn't listed, you have a third-party popup blocker. See below.)
Click Pop-up Blocker Settings.
In the Pop-up Blocker Settings window, type www.hcai.ca as the "Address of Web site to allow" and click the Add button.
Close the Pop-up Blocker Settings window and all Internet Explorer windows.

How can I remove the security display messages that appear when I one move through the different tabs of OCF forms?

Go to Tools > Internet Options
Click on the Security tab
Click on the "Trusted Sites" icon (Green check mark in IE8), then click the "Sites" button just below
Add https://www.hcai.ca to the zone
Click “OK”

How can I print an OCF Form?

When you select the <Print> function for an OCF form in HCAI, you are presented with two options:

open the document as a PDF; OR
save the document as a PDF.

Option #1 allows you to save the file to your own files; option #2 opens the file via the Adobe Acrobat application, from which the file can be printed.

Are statutory holidays counted in HCAI?

Currently, statutory holidays are deducted from the days left in accordance with the SABs timeline.

Does HCAI have a “time-stamp” feature when printing OCF forms?

All OCFs can be printed or saved using HCAI’s <Print> functionality. HCAI currently does not “time stamp” OCFs upon printing. The OCF summary page contains an OCF’s time and date information. When printing an OCF, however, the summary page does not print. That said, an OCF’s summary page can be printed using your web browser’s print function.

A date is recorded on the OCF once it has been adjudication decision has been made. For example, when an adjudication decision is made for an OCF22, the date the decision has been made is found in Part 8, "Signature of Insurer" section, of the printed/saved PDF version of the OCF22.

What do we do if we have claims out of province or out of country?

If OCFs are received from an out of province or out of country health care facility, these OCFs should be adjudicated outside of HCAI because the health care facility is unlikely to be registered with HCAI. HCAI is for Ontario claims/benefits & Ontario health care facilities.

What happens if we receive OCF forms via fax and the health care facility is registered with HCAI? Is a phone acceptable to the facility to advise that they must process through HCAI or do we need to send a letter?

If OCF forms are received via fax from a registered health care facility, the insurer is not required to respond to it. But, as a matter of courtesy, a phone call should suffice. If the health facility has a question about using HCAI, they can contact providersupport@hcaiinfo.ca or their health professional association.

(From the HCAI Rollout Guideline): Section 68 (3.2) of the SABS provides that a document to which this the HCAI Rollout Guideline applies (and it applies to OCF 18s, 22s, 23s and 21s) is deemed not to have been delivered to an insurer unless it is delivered to the CPA as required by this Guideline. If such a document is delivered directly to an insurer (by fax or mail) instead of to the CPA (HCAI) despite the requirements of this Guideline, the insurer is under no obligation to respond to it as the document will be deemed not to have been received by the insurer.

Can all OCF 21s be sent through HCAI? Or, are they matched only to approved OCF 18s, 22s, 23s etc that have been sent through HCAI?

HCAI follows similar rules to the current paper process. That is, OCF21Bs can be sent in HCAI with/or without an approved OCF18 or OCF22. Insurers have the right to waive an OCF18 or an OCF22 as there could be circumstances where no plan exists. Therefore HCAI allows "stand-alone" invoices to be submitted. An OCF21C, however, does require a previously approved OCF23.

Can you attach anything to an OCF 9 to submit with a response to an OCF form?

At this point in time, HCAI does not permit attachments to be sent through the system. “Ticking” the attachment checkbox notifies the health care facility that an associated attachment is being sent to them outside of the HCAI system (e.g. email, Canada Post, courier etc.).

In the OCF18, what does “Submitted Additional Attachments” mean? Is this an electronic attachment or is it coming in separately by paper?

When health care facilities are submitting an OCF18 and also plan to send attachments to the adjuster, they need to indicate on the form that attachments are being sent. HCAI does not currently support electronic attachments, so all attachments must be sent separately via fax or mail. The notification on the OCF18 alerts the adjuster to the fact that additional information is forthcoming. When the adjuster receives the attachments, s/he will indicate the reception date in HCAI on the OCF18.

When are we required to use the <Save> button?

The <Save> button is generally only used if the adjuster cannot complete his or her adjudication response in HCAI at the time the form is being accessed, and wish to save that portion of the response that has been completed.

For example, if an adjuster was partially approving a lengthy plan and didn't have time to finish entering in the various reason codes for the goods and services that weren’t being approved, the responses entered can be saved. This enables the adjuster to return to that form later, and to finish and submit the form. There is also no need to press save for each page: the adjuster can wait and press save at the end, if required.

Please note that if the adjuster has not entered any information into the form, or if s/he can complete their response and submit to HCAI during the same session, then there is no need to use the save feature.

What is the appropriate usage of the <Withdraw> button?

The <Withdraw> button was developed to allow adjusters to change their decision as recorded in HCAI regarding a particular plan or invoice. A common example is when an adjuster makes an adjudication decision in error. The <Withdraw> button will put the plan back in the adjuster’s work list, thus enabling the adjuster to enter a new decision. It should be noted that, because of the real-time receipt of decisions by health care facilities, a phone call should be made to the health care facility alerting the facility to the change in decision if any time has passed before the error is discovered.

Another example of when the <Withdraw> button can be used would be in response to a plan that was not approved and sent to an Independent Examination for consultation. If, after the IE has been completed, it is found that the treatment recommended is reasonable, the adjuster could withdraw their decision and approve the proposed treatment.

When responding to an OCF23, if no policy is in place, do the adjusters answer ‘No” to the question regarding whether a policy was in place and then click on <Submit>? or should an adjuster user the <Do Not Approve button>? If the wrong button is selected, what will happen to the response?

If no policy is in force, then the OCF form would likely appear in HCAI in an "Unmatched" state due to the fact that there is no corresponding claim/claimant information found in the HCAI system. The only answer that the adjuster can give in this case is <Do Not Approve>. The <Submit> button does not appear on forms in an “Unmatched” state.

When responding to an OCF18 and setting reason to pending, a search button appears? What is the purpose of the “search” button?

The reason for the Search button is that, in order to set something into a “Pending” state, the adjuster must select a reason code for putting it into pending. The “Search” function enables the adjuster to search the available reason codes based on the criteria in the drop-down menus.

Why do we need to put reasons on items approved on a partially approved treatment plan?

Items that are approved on a partially approved treatment plan should not need a reason code (we just tested this in the sandbox with an OCF 23 & no reason codes were required for the approved items…is there a specific plan w/which you are having difficulty?). When, however, an item is approved but the cost/price approved is less that what is approved, a reason code is required. If the list of items is lengthy, one way to partially approve is to use the approve all feature (Set Charged Costs to Approved Costs), then manually decline or partially approve certain line items, & then click on the adjuster response button ( ) for each particular line that is either partially approved or declined to enter the reason code.

Where are the <Need to Discuss> and <Amend> buttons located on OCF forms that health care facilities have submitted to Insurers via PMS systems?

The <Need to Discuss> and <Amend> buttons do not currently show up on OCF forms submitted by a health care facility using PMS integration.

How do I know whether an OCF form has been submitted via the Data Entry Centre, a PMS system or directly through the web application?

The mode by which documents submitted to insurers is marked on the top right hand corner of the Summary tab of an OCF form in HCAI.

How am I supposed to respond to an OCF form that has been submitted by the Data Entry Centre?

Adjusters will provide responses to the patient and facility via paper, while the decision itself will need to be recorded in HCAI so that the system recognizes that the OCF form has been adjudicated.