Health Care Facility | Insurers | Related Initiatives  

Setting Up Claim and Claimant Record


About Claims and Claimants

Before we delve into the topic of claim and claimant management and setting up a new claim and claimant record, it is important to understand what the difference is between a claim and a claimant in HCAI.

In HCAI, a claim contains basic information about the policy holder and the claim incident, such as:

  • Claim Number
  • Policy Number
  • Date of Accident
  • Policy Holder Last Name
  • Policy Holder First Name
  • Insurer
  • Branch Name

The claimant contains additional information about the person seeking treatment, such as:

  • Claimant ID
  • Last Name, First Name, Middle Name
  • Address
  • Date of Birth
  • Gender
  • Phone Number
  • Associated Adjuster

A claim can have multiple claimants associated with it, but claimants cannot exist without being attached to a claim. We call a claimant and the associated claim a claim-claimant record.

It is important to note that the adjuster is linked to the claim-claimant record via the claimant, not the claim. If you want to change the adjuster associated with the claim, you must do so via the claimant details screen.

Setting Up a Claim and/or Claimant Record

Enter Claim-Claimant Information

There are two ways a claim-claimant record can be set up in HCAI. It can be set up manually in the HCAI application (www.hcai.ca), or it can be set up via the claim-claimant feed.

The claim-claimant feed sends data directly from an insurer database into the HCAI application. If your organization feeds claim-claimant information into HCAI via a feed, you generally won’t need to set up the claim-claimant record in HCAI manually (though there are some exceptions, so it’s best to familiarize yourself with the process).

Setting up a Claim-Claimant record in HCAI Manually

To set up a claim-claimant record in HCAI, you must have the Form Manager or Claim-Claimant Administrator role at the Insurer level of access.

  1. Click on the Claims tab, the Claims Search screen will appear. (View screenshot)
  2. Click <Add Claim>, Add Claim screen will appear.
  3. Fill in the relevant fields: (View screenshot)
    1. Select the correct Insurer and Branch from the drop-down menus (these fields will automatically populate if you only have one insurer and/or branch).
    2. Enter the Claim and Policy number.
    3. Enter the Policy Holder’s Last name and First Name.
    4. Enter the date of accident.
  4. Click <Save>.
  5. Screen will refresh and Claim Details screen will appear, click <Add Claimant>. (View screenshot)
  6. Claimant Details screen will appear, fill in the relevant fields: (View screenshot)
    1. Claimant ID: this identifier is provided by the insurer and is unique within the claim
    2. Enter the Claimant’s Last Name, First Name and Middle Name
    3. Enter the Claimant’s Address and City of Residence
    4. Select the province of residence from the drop-down list; this list defaults to “Ontario”
    5. Specify the Claimant’s Postal Code
    6. Select an Adjuster from the drop-down menu who will receive associated OCFs for that Claimant
    7. Enter the Claimant’s date of birth in YYYY/MM/DD format, or use the calendar function
    8. Select the gender of the Claimant
    9. Enter the Claimant’s phone number
  7. Click <Save> to save the new claimant details.
  8. If the claimant information matches the information inputted by the facility on the OCF, the document will automatically match to the new claimant record; if not, the user will need to manually match them.

Setting up a claim-claimant record in HCAI via integration channels

If your organization uses a claim-claimant feed, you should note that HCAI will not accept claim-claimant information that is incomplete.

If you cannot locate a claim-claimant record for an OCF that belongs to your organization, it is possible that the data source (e.g. your organization’s claim software) did not list complete information for a claim-claimant record and you may need to escalate internally to ensure all mandatory fields are entered.

If your organization uses integration to feed claim and claimant information into HCAI, you generally won’t need to set up claim and claimant information manually. There are a few exceptions, however, including:

  1. If the claim-claimant record was archived. Claim-claimant records are eligible for automatic archiving two years after the most recent adjudication decision. If a claim-claimant record has been archived, you will need to set up a new claim-claimant record.
  2. If the claim-claimant information was not entered into the feed. In some circumstances, claim-claimant information may be missing from the data source (e.g. the claims software). HCAI will not allow an incomplete claim/claimant record so the record is not created.