OCF-21C - From Scratch and Plan
Contents
1. 8 PART 5 INJURY AND SEQUELAE CODEG cccccessseeeesecensseeeseceasseeeeeoeasseeeseoaaseeseseonsseeessooenneees 8 PART 6 GOODS AND SERVICES 9 TAB c 11 PART 7 REIMBURSABLE BLOCK FEES WITHIN THE MIG OR 11 PART 8 OTHER REIMBURSABLE SERVICES REQUIRING INSURER APPROVAL 13 PART 9 OTHER INSURANCE GOODS AND SERVICES SERVICES CHARGED TO OTHER SOURCES 15 NS ess ERST nwT cS 15 ADDITIONAL INFORMATION iuscsessauas QURE Sea unam cu US S ak nOD ca ERE Eg UM SEE UAS 16 TAB 17 ADDITIONAL COMMENTS amp ATTACHMENTS SR RR RR RR RR 17 Create an OCF 21C in An OCF 21C is used when invoicing for goods and services delivered in the Minor Injury Guideline for accidents on or after Sept 1 2010 or the Pre Approved Framework for accidents prior to Sept 1 2010 In HCAI there are two options for OCF 21C creation 1 Create an Invoice from a Plan This option can be used once your Facility has submitted the associated OCF 23 HCAI 2 Create an Invoice from sc2. 3 5 Injury and Sequelae Codes From Plan When you create an OCF 21C from a previously submitted Plan the injuries on the Plan will be carried over to the Invoice It is possible for you to change the injury codes used Claimants treated in the Minor Injury Guideline MIG or in the Pre approved Framework PAF generally have an injury or injuries consistent with the MIG or PAF Guideline From Scratch List the injuries and sequelae that are a direct result of the automobile accident Each code should be listed only once regardless of how many Health Care Providers will be engaged in the treatment The first line item should reflect the primary reason you are proposing services with the most significant injury first In a case where multiple injuries may be classified as the most significant list the injury requiring the most services first The use of ICD 10 CA codes is intended to convey problems and is not the equivalent of communicating a diagnosis Adding additional lines for injury sequelae codes To add lines for additional injuries simply click the button near the bottom of the 5 box see Figure 8 Figure 8 Injury and Sequelae Part 5 Injury and Sequelae Provide the associated 10 code for injuries and sequelae listing the most significant first that are the direct result of the automobile accident Code Description 5 1340 EJ Whiplash associated disorde
3. Provider Invoice Mumber t First invoice No ves Last invoice Yes Previously Approved Goods and Services For previously approved goods and services please complete the following this invoice for and services described on an OCF 23 in Please enter the HCAI Document Number of the Treatment Confirmation Form OCF 23 to which this invoice corresponds This is the eleven digit Document Number in the Plan Identifier section in the top right hand corner of the OCF 23 If you wish to indicate that this submission is exempt from providing the OCF 23 number answer No to the question above type in exempt 23 Document Number 12052100002 From Scratch Click Yes if the goods and services being invoiced are included in the associated Plan and type the Plan s Document Number o If you do not have the Document Number select Yes and type exempt all lowercase into the Document Number field FSCO s HCAI Guideline explains when it is appropriate to request an exemption f your Invoice includes goods and services that not described in an associated Plan select This indicates you have selected an exemption from providing a Document Number 4 Payee Information Within the account s Facility Management section there is a question Payee Field Editable on Invoices o If Yes is selected the Make Cheque Payable To field m
4. 2012 05 03 Code Enter the intervention by typing it directly into the field under Code Or use the code search utility by clicking the blue ellipses button next to the Code field see Figure 9 f using the search utility select either Canadian Classification of Interventions or GAP Attribute These codes are used to indicate how the service was delivered or for example the number of views in an X ray study Attribute is not mandatory and can be left blank Provider reference Use the dropdown list to select the Health Care Provider who delivered care on a given date a If more than one Health Care Provider delivered care list only the one who was most responsible for each visit that is listed on the Invoice om Insert one Provider for multiple line items There is a shortcut for inserting one Provider name in multiple line items as follows 1 Complete all fields except for the Provider Reference fields 2 Tick each box to the left of the each completed line item see Figure 11 3 Click the button and select the name of the Provider from the dropdown list Figure 11 Apply one Provider to several line items Part 6 Goods and Services Rendered Providers are required to declare the information requested below on every treatment service and good delivered Failure to provide this information may delay payment Date Services Rendered F I 20 12 08 44 2012 06
5. from the insurance Adjuster Policy Number is also available on the Motor Vehicle Liability Insurance Card pink slip Claim Number and Policy Number may be the same 2 Enter the accident date forms will not be processed without an accident date the Applicant Patient has overlapping injuries from more than one accident use the date of the accident that is most relevant to the injuries being treated Invoice Identifier This information will be populated when the Invoice is submitted No action is required Part 1 Applicant Information From Plan Data will be populated from the information entered on the OCF 23 No edits are possible From Scratch creating the OCF 21C from scratch the Applicant or substitute decision maker should provide this information to the Facility Date of birth of the Applicant Patient Gender of the Applicant Patient Part 2 Auto Insurer Information From Plan These fields are populated for you when creating the OCF 21C from a Plan From Scratch Applicant or substitute decision maker should provide this information to the Facility Independent adjusting companies and Adjusters Independent adjusting companies may be hired by Insurers to adjudicate Claims but the application does not list independent adjusting companies To direct OCFs appropriately you should determine typically by asking the Applicant Patient or the independent A
6. who have been associated with your faciliby will be available facility administrator can add a provider from the Facility Management tab Provider Name Provider Profession r suBMIT CANCEL Insert Provider s for multiple line items There is a shortcut for inserting one or more Provider name s in multiple line items as follows 4 Complete all fields except for the Provider Reference fields 5 Tick each box to the left of each completed line item see Figure 11 6 Click the button and select the name of the Provider s from the dropdown list ee Cost Enter the cost for each block of treatment Calculate Click EnEEE to see the Estimated MIG or PAF Sub total Part 8 Other Reimbursable Goods and Services Approved by the Insurer Only applies to accident dates prior to Sept 1 2010 From Plan When the Invoice has been created from an OCF 23 it is possible to populate this section with the goods and services listed on Part 11 of the OCF 23 To do this 1 Click note this button will not appear when creating an Invoice from an Archived Plan Figure 16 Apply codes from submitted Plan Part 8 Other Reimbursable Goods and Services Approved by the Insurer Other reimbursable goods and services must be within the PAF or Minor Injury Guidelines HST applies to a good or service check the Proposed Tax checkbox on that line item Date Services Code Attr Provider Reference
7. 0 HCAJ populates the proposed and calculated tax columns with the HET rate 13 You may overwrite the Proposed Tax amount if you are charging a tax value that is different from HST CALCULATE IR G is possible to request payment for amounts greater than less than those proposed on a Plan but the Insurer may request an explanation Additional Information In Tab 4 near the bottom of the HCAI page there is space that permits comments if there is a need to provide the Insurer additional explanations clarifications Only 500 characters are allowed here If more space is needed use 5 Figure 21 Additional information Additional Information Make cheque payable to Acme Rehab Other Information Fl aH i CANCEL PRINT SAVE SUBMIT 96 5 Additional Comments amp Attachments Figure 22 Additional comments and attachments Additional Comments Meese note that the dic T DTI E not considergd compete the attachments If amy are indicated arg receryed ey tha insurer mandatory ic ES of dacuments repnoris that are berg seni rite baing sami iT amy Family physician report enclosed HCAI permits Facilities to do the following o Offer more information to Adjusters by using the space provided in Tab 5 O Advise Adjusters that additional documentation attachments is being sent which the Insurer requires t
8. 090900 Health Claims for Auto Insurance OCF 21C MANUAL FOR WEB USERS July 2015 TABLE OF CONTENTS CREATE AN OCF 21C IN 2 FROM PLAN SUBMITTED VIA 2 Dese tes 2 Ma E A 3 4 SERE ET CROIRE PN SEIN KEENRNED D 4 INVOICE IDENTIPIER sicscacesscdcsnasvousscuyaransninssaceduatssusnaswecsndusivinerdvasavedudieauueaswiecndajitersnddisenadedinayveaiel 4 PART 1 APPLICANT INFORMATION 4 PART 2 AUTO INSURER INFORMATION raa a rana e 5 jj 6 PARTS INVOICE DETAIL lt 6 PART 4 PAYEE INFORMATION weisiissnasssesssuadecedindncssscnnssdaaanuedeundsadeosdsoeussssavusntaincunscuadbsebeddnsersniads 7
9. 19 a Code Description Attr Provider Reference Quantity Measure BR Therapy wristioint Brand Alison Therapy elbow joint Brand Alison i Bl 7 nerve s of pelvis nio Brand Alison i 218 Bi 2 J je eg DELETE APPLY PROVIDERS E Use these buttons with the checkboxes on the left CONFIRM CODES Quantity and unit measure Enter the quantity and unit measure of service that will be provided during a single treatment visit session o Example o Itis 15 minutes 2 0 25 HR 1 procedure 1 PR 1 good like a back support 1 GD 10 km 10 KM 1 session 1 SN important to use the correct unit measure that corresponds to the service described Most treatment interventions should use the PR procedure or HR hour measure All goods must use the GD goods measure Disbursements such as parking may be conveyed using Other AXXOT goods and the GD measure must be used Mileage expense must be conveyed using the KM kilometre measure Do not use GD for documentation review or preparation 10 4 Part 7 Reimbursable Fees within MIG or First Date of Service The first date that service was provided should be listed for each treatment For block fees this is the date the block of services was initiated Dates should be formatted yyyy mm dd and may be cut and pasted if several line items were delivered o
10. C TABS The OCF 21C in HCAI appears organized under five tabs Figure 4 OCF 21C tabs Create OCF21C E STEP Mo 7 User Manual e S P 9 CANCEL PRINT SAVE Tab 1 Claim Identifier Invoice Identifier Part 1 Applicant Patient Information Part 2 Auto Insurer Information Tab 2 Part 3 Invoice details Part 4 Payee Information Tab 3 Part 5 Injury and Sequelae Codes Part 6 Goods and Services Rendered Tab 4 Part 7 Reimbursable Fees within the Minor Injury Guideline or Pre approved Framework Part 8 Other Reimbursable Goods and Services Approved by the Insurer Part 9 Other Insurance for goods and services on this Invoice Additional Information Tab 5 Additional Comments and or Attachments 1 Claim Identifier Figure 5 Claim Identifier n HcRO6 Create mm 2 NEXT 1 User Manual p r CANCEL PRINT SAVE Claim Identifie invoice Identifier ant D Invoice Number OCF Type 21C Date of Accident 2012 03 01 Date 2012 07 06 Source Web OCF Effective Date 2010 09 01 From Plan Data will be populated from the information on the submitted OCF 23 No edits are possible From Scratch 1 Enter Claim Number and or Policy Number Applicant must provide the Claim Number if known the Policy Number and the date of the accident Claim Number and Policy Number can be obtained
11. COSTS FROM RATES figure 16 correct rate to apply to your Invoice clic omanually enter or override the rate enter the amount in the Cost field instead e information on how to calculate costs from rates and how to set a Provider s Default Hourly Rate is explained in the Provider Hourly Rates Did You Know on HCAlinfo 6 If Tax is applicable to a line item check the box in the Tax column Figure 18 Part 8 goods and services that were approved by Insurer 8 Other Reimbursable Goods and Services Approved by the Insurer t LE cCneckl Attr Provider Reference A XX KM B Miegge Pravider pewon Uu Dianna Lueck Onsite warkhome APPLY CODES FROM PLAN CONFIRM CODES 9 CALCULATE COSTS FROM RATES From Scratch Date service rendered Use the calendar utility to select the date on which the service was delivered or insert the date yyyy mm dd Code codes required to populate Part 8 are all and GAP codes Attribute These codes are used to indicate how the service was delivered or for example the number of views in an X ray study Attribute is not mandatory and can be left blank Provider Reference Use the dropdown list to select the Health Care Provider who delivered care f more than one Health Care Provider delivered care list only the one who was most responsible for each visit that is listed on the Invoice Quantity Measure E
12. Quantity Measure 8 B ES B 90 Rendered EJ B GD Bj EN B so v n o mm Use these buttons with the checkboxes on the left 2 A screen will open that has a calendar to the right of each line of goods and services that were listed on the Plan Use the calendar function see Figure 15 to select each date on which the specified service was delivered to the patient 3 When all lines have been completed click again Figure 17 Select dates on which service was delivered Create OCFZ1C Saline each previous approved geod amd service by using the calendar ideni ny thet aae 2 c dekvery When all sendicer ana meten dabes npo been ieniried cick Apply Codes from Plan retuen fo ine invoice without applying fee deles of deiveny cick Cannel PVAWOR wor hans resins iforesnbews 1 3 Exe 61 14 18 20 21 mmo EE oe 4 All of the goods and services along with the Provider Reference Quantity Measure and Cost will populate the Invoice e Note It is possible to edit the lines of goods and services It is also possible to add goods or services that did not appear on the Plan 5 Apply the Default Hourly Rate When the Providers listed on your Invoice were added to your Facility in HCAI there was an option to assign a Default Hourly Rate If the rate assigned is the k CALCULATE
13. ations Minor Injury Guideline blocks and Pre approved Framework blacks Only Minor Injury Guideline codes and Pre approved Framework codes are approved codes for selection on Part 7 of an OCF 21C To begin the search select the Section that is appropriate for your clinical situation To narrow down the search results select an Intervention and a Group prior to clicking the Search button Code Domain GAP MIG and PAF only Note codes are not available under Part 7 of the OCF 21C If PAF date of accident on or before Sept 1 2010 do not include Home worksite school visit and intervention here The maximum fees payable by Insurers for pre approved services are listed in the MIG Guideline learn which services are pre approved read the MIG Guideline published by the Financial services Commission of Ontario and available on the FSCO website www fsco gov on ca Provider reference Use the dropdown list to select the Health Care Provider s who delivered care for a given treatment block At least one Provider must be listed for each treatment block If more than one Health Care Provider delivered care list up to three Providers who were most responsible for each treatment block listed on the Invoice The Providers will be displayed in the order they were selected Figure 15 Select Providers Please select one or more providers for this line item At least one provider is required Only the providers
14. ay be changed o If No is selected the field next to Make Cheque Payable To may not be edited Figure 7 Payee Information Yes selected for Lock Payable Part 4 Payee Information Facility Name Ontario Physio Care HCAJ Facility Registry Number 100634 FSCO Licence Number LicNo_ 100631 Make Cheque Payable To Ontario Physio Care Payee First Name Payee Last Name Payee Number Billing Address Address 1 200 Main St Address 2 City Toronto Province Ontario Postal Code M1M 1M1 Service Address Same as biling address Phone 418 555 5555 Fax 418 111 1111 E mail Sue email ca THE AUTHORIZED SUBMITTER CERTIFIES THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT THE AUTHORIZED SUBMITTER UNDERSTANDS THAT 15 AN OFFENCE UNDER THE INSURANCE ACT to knowingly make a false or misleading statement or representation to an insurer under a contract of insurance THE AUTHORIZED SUBMITTER FURTHER UNDERSTANDS THAT IT 15 AN OFFENCE UNDER THE FEDERAL CRIMINAL CODE for anyone by deceit falsehood or other dishonest act to defraud or attempt to defraud an insurance company This information will be used for processing payments of claims identifying and analysing the nature and costs of goods and services that are provided to automobile accident victims by health care providers PREVENTING FRAUD AND DETECTING FRAUD WHERE THERE ARE REASONABLE GROUNDS TO SUSPECT FRAUD Note Authorized signatures obtained during registration
15. djuster the name of the licensed Insurer that insures the Applicant Patient Policy Holder Details If the injured person seeking treatment is the Policy Holder select Yes to the question Is the Policy Holder the same as the Applicant fthe injured person is not the Policy Holder select No and enter the last name of the Policy Holder The name of the Policy Holder can be obtained from the pink slip of the proof of insurance form 2 Part 3 Invoice Details f your Facility uses an internal Invoice numbering system you may enter it in the Provider Invoice Number field o This number will appear in the HCAI worklist and will help you locate an Invoice after you have submitted it o not a mandatory field and may be left blank Click Yes for First Invoice if your Facility has not previously invoiced the Insurer for the associated Plan Click Yes for Last Invoice if this is the last Invoice to be submitted for the associated Plan Previously Approved Goods and Services From Plan When creating your Invoice from an OCF 23 the Plan s Document Number will be auto populated and will not be editable It will also link to the associated Plan Figure 6 Invoice details Part 3 Invoice Details To aid in the decision making process please identity the plan for this claimant that is associated with this invoice and whether or not this is the first or last invoice under this plan
16. le Goods and Services Approved by the Insurer Minus sum of all Ministry of Health and Long Term Care amounts Minus Other Insurer 1 2 sum of all amounts received or payable to you from other Insurers The following amounts are not added to the calculation of the Auto Insurer Total Prior Balance the Auto Insurer Total from your last Invoice Overdue Amount Payments Received from Auto Insurer since your last Invoice to calculate Overdue Amount 15 Interest amount is added to the total Interest owed to your HCF as a result of the Overdue Amount When all of the proposed goods and or services have been entered and any required fields in the Totalling section have been completed click CALCULATE calculates Tax HST and enters the amount into the Auto Insurer Total If you wish to manually enter a different tax amount for your invoiced goods services l Click and uncheck the button underneath the Totalling box ll Enter the new amount in the Tax if applicable field Click 2000 for the new Auto Insurer Total Note Taxes are included in the MIG block billing fees The OCF 21C only permits taxes to be selected for line items in Part 8 Figure 20 Totalling Pre approved Sub total Other Goods and Services Minus Minus Other Insurer 1 2 Tax if applicable Prior Balance Payment Received from Auto Insurer Interest Auto Insurer Total 25 0
17. n the same date The calendar utility may also be used Figure 12 Date Services Rendered Date Services Rendered 7 2012 05 03 Code Enter the intervention by typing it directly into the field under Code or use the code search utility by clicking the blue ellipses button next to the Code field Figure 13 Part 7 Reimbursable Fees within the MIG or PAF Part 7 Reimbursable Fees within the Minor Injury Guideline or Pre approved Framework Guideline to which this invoice applies Minor Injury Cost specifies the total cost for a given block First Date of Code Description Provider Reference 2012 08 02 bd M IG D0 Doe John BJ 2012 08 08 hd M IG 01 Baker Dan EE Use these buttons with the checkboxes on the left Minor Injury Guideline or Pre approved Framework Fee Totals 890 00 CALCULATE f using the search utility select the appropriate GAP code MIG or PAF only sd s Figure 14 Search for MIG PAF Codes GAP codes are developed by The Insurance Bureau of Canada in conjunction with automobile insurers and health care providers to cover those items billed to automobile insurers by providers that are not covered by the Canadian Classification of Health Interventions Items that fall outside of the realm of a medical procedure intervention service are coded by using GAP codes These include goods supplies assistive devices mileage travel time independent medical examin
18. nter the quantity and unit measure of service that was provided during the Insurer approved intervention 14 Cost Report the cost per service as described in the line Example If the service was delivered for 0 5 HR the Cost column should reflect the cost to deliver that service by the provider listed for 0 5 HR Note Do not insert the hourly rate in this column You may also calculate costs using the Provider s default hourly rate Example 15 minutes of massage 0 25 HR by a massage therapist 25 of the RMT s hourly fee 0 25 x 53 66 13 41 This amount should be entered in the field under the Cost column If Tax is applicable to a line item check the appropriate Tax box es To learn which services are pre approved read the PAF Guideline published by the Financial Services Commission of Ontario and available on the FSCO website www fsco gov on ca Part 9 Other Insurance for goods and services on this invoice 1 If amounts are payable by another Insurer enter the amounts within the Other Insurance for goods and services on this invoice section Do not use a negative sign for these amounts These amounts will be deducted from the amount owed by the Insurer 2 For amounts previously identified for payment by another Insurer but subsequently ruled ineligible select Yes for the question Do you want to claim any amount not reimbursed by other insurance sources Enter the amounts for
19. o adjudicate the form How should attachments be sent Attachments must be faxed mailed directly to the Adjuster O Attachments cannot be sent electronically via HCAI and should not be sent to HCAI To indicate that an attachment is being sent to the Adjuster check off Attachments being sent if any o If this box is ticked the Facility must use the space below to describe the attachment being sent sd
20. r V AD 1 with complaint of neck pain stiffness or tenderness only o CONFIRM CODES Refer to Appendix C which is the partial pick list of injury problem codes available at www hcaiinfo ca or contact your Health Professional Association 6 Goods and Services Hendered Provide details of specific interventions that were delivered e g exercise education stimulation TENS laser US etc Do not use MIG or PAF block billing codes in this section See Part 7 for Block Fees Figure 9 Goods and services lines Part 6 Goods and Services Rendered Providers are required to declare the information requested below every treatment service and good delivered Failure to provide this information may delay payment Date Services Code Description Attr Provider Reference Quantity Measure Rendered 2012 08 01 HXXMR A Med Rehab Smith Dave 1 00 PR 2012 08 01 1 5C 02 2 Exercise spinal vertebrae Smith Dave B 1 00 PR 20120604 7 5 fW Education promoting health and Smith Dave 100 PR B B so hd n n eD PESE Use these buttons with the checkboxes on the left Date service rendered All dates on which the Claimant attended treatment should be listed Dates should be formatted yyyy mm dd and may be cut and pasted if several line items were delivered on the same date The calendar utility may also be used Figure 10 Date Services Rendered Date Services
21. ratch This option is used when your Facility has not submitted an OCF 23 HCAI From a Plan Submitted via HCAI Figure 1 Plans gt Adjuster Response sub tab Health 4 Life mvoices SEARCH MANAGE User Manual DE gt 23 WORK IN PROGRESS PENDING DRAFT Plan Management Adjudicated riter by 1 0 ocr Adjudicated 1 of 9 The following items were recently adjudicated View 2 Rd 12345 ype ati nA cC gt OCF T gt Patient gt Status D Jate Res ponde 4 OCF18 Ferguson Approved 2012 06 25 OCF23 Diaz Declined 2012 06 25 i Locate and open the submitted by clicking on the magnifying glass icon to the left of that Plan see Figure 1 Once the Plan opens click the GREATE INVOICE Dutton see Figure 2 and the OCF 21C is created of the fields will be auto populated from the submitted OCF 23 Figure 2 Create Invoice from Plan Review OCF23 CREATE PLAN CREATE INVOICE vTHDRAW ANCEL Claim identifier Return this Torm tac RTT Appkcant Name Smith Joe KOH Re Document Number 12062100002 From Scratch Figure 3 Invoices global tab Mark s Healing Hands v 2 Wanye Go to Invoices tab and any sub tab see Figure 3 m Select OCF 21C from the dropdown list and click the button A blank 21 will open OCF 21
22. the corresponding Insurer in the section that appears a When the category Other is used specify the type of services covered e g dental psychological optometric 3 Click the 0 button to see the total for each line Figure 19 Other insurance Other Insurance for goods and services on this invoice Enter the total amounts received or estimated to be payable to you on this invoice for goods and services from other insurance sources amp g Ministry of Health and Long Term Care and Extended Health Care plans to which the applicant is eligible Categorize amounts by Chiropractic Physiotherapy Massage Therapy and Other When the category Other is used specify the type of services covered e g dental psychological optometric Use the section below to indicate the amount you have received or will receive directly from the collateral source or applicant Enter the amounts as positive values These amounts will be subtracted from the sub total to determine the amount owed by the automobile insurer MOH Insurer 1 Insurer 2 Chiropractic Physiotherapy Massage Therapy Other Services Total O 000 200 00 fr 009 Do you want to claim any amount not reimbursed by other insurance sources S Totalling Pre approved Sub total Proposed Goods and Services Sub total calculated in Tab 4 Other Goods and Services Calculates amounts from Part 8 Other Reimbursab
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