OCF-23 Manual for Web Users
Contents
1. 8 PART 9 GUIDELINE SERVICES PRE APPROVED SERVICES J 8 PART 11 OTHER GOODS OR SERVICES 8 C PUDE vic TENE 10 EXPLANATION OF GOOD amp SERVICES diris diac IILI ISI IIS aaa saskwkaswkanasaaqanakanaqanwaqyaaskunkuaaanwawa 10 TAD A 11 ADDITIONAL COMMENTS S ATTACHMENTS 22 2 puasana aaa aaa 11 SIGNATURE ON OCF 23 PRINTING THE COMPLETED OCF J J 11 Create an OCF 23 in HCAI An OCF 23 is used for patients with injuries that are suitable for treatment in a Pre Approved Framework or in the Minor Injury Guideline To create an 23 User Manual Plan Managernent Filtor by ERATES 5 lt CREATE NEW Go to the Plans tab and any sub tab Select OCF 23 from the dropdown list and click CREATE NEW A blank OCF 23 will open OCF 23 TABS The OCF 23 in HCAI appears organized under four tabs Figure 2 OCF 23 tabs Create OCF23 HEAO SEP 12 BE User Manual CANCEL Claim Identifier Part 1 Applicant Patient Information Part 2 Auto Insurer Information Part 3 Other Insurer Information Tab 2 Part 4 Signature of Initiating Health Practitioner Part 5 Injury and Se2. 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 The quantity refers to the number of times over the course of the treatment plan you will deliver the service described by the code o Example If you plan to do one OWRI visit enter 1 00 Or you can enter the number of hours you plan to use for the visit by entering the number and selecting the unit measure HR 70 kilometres 70 3 post PAF extension visits 3 Measure Use the measure appropriate to the service being described o Example 15 minutes 0 25 HR 1 procedure 1 PR 1 good like a back support 1 GD 10km 10KM 1session 1SN Calculate Costs from Rates e 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 correct rate to apply to your Treatment Plan click sic manually enter or override the rate enter the amount in the Cost field instead Cost Enter the amount you estimate the line item will cost One Provider and multiple line items There is a shortcut to inserting one Provider name in multiple line items Complete fields except for the Provider Reference fields ll Tick each box to the left of each completed line item o Select
3. Signatures are not transmitted to the Insurer however hard copies of the form must be printed and signed and kept on file at the HCF To obtain signatures the entire OCF should be completed To print a form Click on the button located at the top and bottom of the HCAI application web page User Manual b d j ih DELETE CANCEL PRINT SAVE SUBMIT Claim Identifier Return this form to Plan Identifier Additional Comments EL ee Ee BS ele be muB see eee eee pam Eines ieee ew ore ees res eet dra Eu ere Ee eee Bs bel EV soe cum 11
4. with the applicant THE HEALTH PRACTITIONER CERTIFIES THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT THE HEALTH PRACTITIONER UNDERSTANDS THAT IT 15 AN OFFENCE UNDER THE INSURANCE ACT to knowingly make a false or misleading statement or representation ta an insurer under a contract of insurance THE HEALTH PRACTITIONER FURTHER UNDERSTANDS THAT IT IS AM 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 effects and costs of and services that are provided to automobile accident victims by health care providers and DETECTING AND PREVENTING FRAUD Q Yes Signed Date 2014 11 07 w Is the Provider the first Initiating Health Practitioner Name of Provider e Select the Health Practitioner who has been added to your HCAI Provider list from the dropdown list Profession e If the Health Practitioner has more than one profession select the appropriate one from the dropdown Is the signature on file Answer Yes or No OCF 23 cannot be submitted unless the answer to this question is Yes o Use the calendar or insert the date of signature yyyy mm dd in the field beside Signed Date Is the Provider the initiating Health Practitioner Answer Yes or No Part 5 In
5. 0900 Health Claims for Auto Insurance OCF 23 TREATMENT CONFIRMATION FORM MANUAL FOR WEB USERS July 2015 TABLE OF CONTENTS CREATE AN OCF 23 IN HCAI 2 ele 1 ilm 2 TAD e ees 3 CLAIIDENTIFIBE 3 SE ji pr ese 3 PART 1 APPLICANT INFORMATION U u u uuu u 3 PART 2 AUTO INSURER INFORMATION UU UU 3 PART OTHER INSURER INFORMATION 4 pa 5 PART 4 SIGNATURE OF INITIATING HEALTH PRACTITIONER 5 PART 5 INJURY AND SEQUELAE INFORMATION u 6 PART 6 PRIOR AND CONCURRENT CONDITIONS J Q nana J J T J J 7 PART 7 BARRIERS TO RECOVFRY eene nn nnns annes nass ases u 7 PART 8 SIGNATURE OF APPLICANT eene nennen nennen nnn u uu 7 TAB
6. 6 Prior and concurrent conditions Part 6 Prior and Concurrent Conditions The information provided in this section will help the insurer to better understand the applicants pre accident status and informs the insurer in advance of any pre existing condition that may affect the applicant s response to the treatment given within the PAF or Minor Injury Guideline Provide relevant information in response to these questions to the best of your knowledge and based on information from the applicant a Was the applicant employed at the time of the accident Q Yes b Prior to the accident did the applicant have any disease condition or injury that could affect his her response to treatment for the injuries identified in Part 5 No Q Yes explain Unknown Part 6 informs readers whether pre morbid conditions or co morbidities exist Provide relevant information to the best of your knowledge based on information supplied by the patient guardian substitute decision maker Part 7 Barriers to Recovery Figure 7 Barriers to recovery Part 7 Barriers to Recovery Identify any barriers to recovery that may affect the success of this treatment for this particular applicant For assistance in identifying barriers to recovery please refer to the user manual at ww w hcaiinfo ca A Have you identified any other barriers to recovery yes Please Explain Had prior WAD injury 2 years ago Re
7. ementary goods and services A Available for PAF Guideline or MIG Part 11 Other Goods or Services This section is applicable only for accidents that occurred before September 1 2010 Figure 9 Other goods and services requiring insurer approval T Fart 11 Other Goods or Services Within the Guideline Rec uiring Insurer Approval TRIE Scion applicable onh Sor accidents far occur besore September 1 3010 Please fill out alll Goods and services and associated kursu Payment by auo Insurer Is Secondary fo salab collateral benem Riester fo User mamal at www ca for coding information Anbe codes are described In fie manual Gs Coda Attr Provider Refaranca Rete Dianna Lueck MN Dianna Lueck Dianna Lueck NN Totalling CALCULATE Code Enter the PAF code by typing directly into the field or use the search utility by clicking the blue ellipses E next to the code field Attribute This field is not mandatory for correct completion of Goods or Services These codes are used to indicate how the service was delivered or for example the number of views in an x ray study The absence of attribute codes means that the service was rendered directly in person to one individual by one individual Health Provider and required continuous attendance Refer to Appendix B for more information about Attributes Provider reference Use the dropdown list to select the Health Care Provider who delivered care on a given date
8. icant s personal spousal or parental extended health plan to pay or partially pay expenses listed in the form opace is available for up to two other Insurers in the event that the Applicant is covered by more than one policy for example both the Applicant and the Applicants partner or legal guardian have extended health benefits Tab 2 Part 4 Signature of Initiating Health Practitioner Figure 4 Signature of health practitioner Part 4 Signature of Initiating Health Practitioner Please indicate that there is a provider signature on file Values marked with an asterisk are mandatory fields required for submission Name of Provider Morson Sally Profession Chiropractor 879 Facility Name Ontario Physio Care Facility Registry Number 100631 FSCO Licence Number LicHo 100631 Service Address 200 Main St Address 2 City Toronto Province Ontario Postal Code M1M 1M1 Phone 416 555 5555 Fax 418 111 1111 E mail Suegemail ca is the signature on file The health practitioner certifies that the goods and services contemplated are reasonable and necessary for the treatment and rehabilitation of the applicant for the injuries identified in Part 5 and the treatment proposed is in accordance with the PAF Guideline if the accident occurred before September 1 2010 or the Minor Injury Guideline if the accident occurred on or after September 1 2010 The health practitioner has reviewed the proposed treatment
9. jury and Sequelae Information List the injuries and sequelae that are a direct result of the automobile accident Descriptions will be provided with the corresponding injury code ICD 10 CA 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 classify problems it is not the equivalent of communicating a diagnosis Adding additional lines for injury sequelae codes To add lines for additional injuries simply click on the button near the bottom right of the Injury and Sequelae Codes section Figure 5 Add additional injury problem code line Injury and Sequelae Codes Provide the associated ICD 10 C code for injuries and sequelae listing the most significant first that are the direct result of the automobile accident descriptions or Search for codes using the button Code Description R 80 EJ Isolated proteinuria R 00 0 g Tachycardia unspecified 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 Part 6 Prior and Concurrent Conditions Figure
10. mation The Applicant 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 The 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 Adjuster 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 the 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 Part 3 Other Insurer Information The Patient guardian or substitute decision maker can advise whether the Patient has other insurance The auto insurance system requires other insurance plans to be accessed before auto insurance health benefits are accessed Health benefits may be available from the Ministry of Health and Long Term Care MOH or through an appl
11. quelae Information Part 6 Prior and Concurrent Conditions Part 7 Barriers to Recovery Tab 3 Part 8 Signature of the Applicant Part 9 Guideline Services Part 11 Other Goods and Services within the Guideline Requiring Insurer Approval Tab 4 Additional Comments and or Attachments Tab 1 Claim Identifier Create OCF23 SS LLL HC I STEP 2 a NEXT amp 7 User Manual CANCEL PRINT SAVE Claim Identifier Pian identifier Piensa provide ihe regured dam Geteds Either the Ciim Number ibe OCF 23 Policy Number i as does the RERO Date 201 HE Source Wien Policy Number OCF Effective Date 2010 08 01 We Date of Accisent 2020876 1 Enter Claim Number and or Policy Number The 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 from the insurance Adjuster The 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 If 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 Plan Identifier This information will be populated when the Plan is submitted No action is required Part 1 Applicant Infor
12. solved after 3 months of PT and chiro care lf there are circumstances that may affect a claimant s recovery select Yes o If you select Yes explain the barrier including any yellow flags identified in the PAF Guideline that may affect the success of this treatment Part 8 Signature of Applicant In HCAI select Yes or No to the question Is the applicants or substitute decision maker s signature on file o If you select Yes confirm the name of the person who signed then select the signed date Select Yes or No in response to the question Was the applicant s or substitute decision maker s signature waived by the insurer Tab 3 Part 9 Guideline Services pre approved services Figure 8 Pre approved Services Part 9 Guideline Services Blect the goods and services to be delivered and enter the expected charged fee Refer to the user manual at ww w hcaiinfo ca for coding information Attribute codes are described in the manual Description Estimated Fee Minor Injury 350 00 X Ray of the Cervical Spine lect a view m X Ray ofthe Thoracie Spine X Ray ofthe Lumbar Spina X Ray of the Lumbosacral Spinal lect a view Part Sub total 2150 00 CALCULATE Identify the Guideline which is applicable e Select PAF for accidents that occurred before September 1 2010 or Minor Injury Guideline MIG for accidents that occurred on or after September 1 2010 Suppl
13. the name of the Provider from the dropdown list Ill Click on the button Calculate When all of the proposed goods and or services have been entered click CALCULATE Explanation of Good amp Services Use the space below the Totalling to provide more detail if the CCI code doesn t offer enough details If there is not enough space in this section you may also use the Additional Comments field in Tab 6 10 Tab 4 Additional Comments amp Attachments Figure 10 Additional comments and attachments Additional Comments Please note that the document is not considered complete until the attachments if any are indicated are received by the insurer It is mandatory to V Attachments being sent if any Family physician report 2 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 to 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 Signature on OCF 23 Printing the completed OCF
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