Invoicing on HCAI: It's not just for licensed facilities / November 24, 2016
They are rare but they are out there—adjusters should be prepared to receive and render an adjudication decision on an OCF-21B or OCF-21C from an unlicensed health care facility in HCAI.
As per FSCO’s May 2015 HCAI Guideline, the process for submitting and adjudicating invoices changed on June 1, 2015. Facilities without an active service provider licence cannot receive direct payment and claimants are required to submit a paper copy of the OCF-21 to their insurer to be reimbursed for treatment goods and/or services.
Regardless of their licence status, all health care facilities must submit the OCF-21 via HCAI.
Submission of invoices from unlicensed facilities: A process overview
When a facility submits an OCF-21, the HCAI system uses FSCO’s service provider licence data to automatically validate whether the facility had a valid service provider licence at the time the service was rendered to the claimant.
Facilities without a valid service provider licence both at the time of submission and when the treatment goods and/or services were provided must print the OCF submitted via HCAI and provide the paper version to the claimant.
The claimant must submit the paper OCF-21 to the insurer for the submission to be deemed received. Once the paper copy with a valid document number is received, the Insurer must mark their adjudication decisions on the form in HCAI.
Reimbursement for treatment goods and/or services provided is to be paid directly to the claimant.
Blank ‘Days Left’ field? You likely received an OCF from an unlicensed facility
Adjusters can spot an OCF-21 from an unlicensed facility from a mile away. This is because the ‘Days Left’ column is blank when the facility has indicated they are not the payee.
The field is intentionally left blank because the insurer must await the paper copy of the OCF-21 from the claimant in order for the form to be deemed received. HCAI has no way of knowing when the paper copy was received by the insurer and therefore it is unable to calculate the days left.
An OCF-21 from an unlicensed facility still requires a response on HCAI
Even though unlicensed facilities cannot receive direct payment for their services, adjusters must still render a decision on the OCF in HCAI. This mandatory process ensures data about the adjudication decision is accurately captured.
To make an adjudication decision on an OCF submitted by an unlicensed facility in HCAI, the insurer must attest they have received a paper copy of the form and indicate the date of receipt in the ‘Signature of Insurer’ section of the OCF-21.
Want to learn more?
For more information, please refer to the Service Provide Licensing page in the Related Initiatives portal of HCAIinfo. Insurer users are advised to review the site to understand their responsibilities regarding Service Provider Licensing and HCAI.