Health Care Facility | Insurers | Related Initiatives  

HCAI Governance

Health Claims for Auto Insurance (HCAI) is part of an ongoing effort to improve the delivery of health care benefits to Ontarians injured in automobile collisions. Building on the Auto Insurance Standard Invoice, introduced in 2001, HCAI seeks to automate the exchange of standardized health claim information between health care providers and insurance companies. As of February 1, 2011, it was mandatory that all insurers and participating health care facilities be registered with HCAI.

The Financial Services Regulatory Authority of Ontario (FSRA) governs use of HCAI via the Health Claims for Auto Insurance Guideline. This Guideline outlines the responsibilities of Participating Insurers and Participating Facilities as well as the Superintendent-approved Ontario Claims Forms (OCFs) that must be submitted via HCAI. This Guideline also designates Health Claims for Auto Insurance Processing (HCAIP) as the Central Processing Agency (CPA) whose primary role is to act as the agent of the insurer to receive specified documents on their behalf.

The CPA will confirm that the OCFs are duly completed and contain all of the information required. The documents are then made available for access by the insurers to whom they are addressed. The CPA also acts as an intermediary for the purpose of enabling insurers to communicate information such as claims approval and payment decisions electronically back to the submitting Health Care facility.

Health Claims for Auto Insurance Processing (HCAIP) is a not-for-profit Ontario corporation established and funded by the insurance industry and operated by a board of directors that includes representatives of the insurance industry and health care communities.

Decisions about the HCAI application are vetted through a governance structure comprised of officials within the insurance industry, which fully funds the HCAI application.

Neither HCAIP nor the Insurance Bureau of Canada participates in rendering adjudication decisions on OCFs in HCAI. Insurers are accountable for making and providing these decisions.

For more information on IBC’s HCAI governance groups, please visit IBC’s member site.