OCF-23 Treatment and Assessment Plan

Claim Identifier and Applicant Information

This section contains details about the claim, and information about the Patient. The Applicant (Patient) or Substitute Decision-maker should provide this information. Carefully entering claim identifier and Applicant information is important for matching purposes. View Submitting and Storing forms for more information on matching. (View screenshot)

Claim Identifier

1. You must enter either a claim number or a policy number. Only one of these numbers is required, not both. However, if you have both claim and policy number, it is helpful to insert both for matching purposes.

2. Enter the date of the accident using the calendar tool, formatted as shown.

Applicant Information

The following fields are mandatory: Date of birth, gender, first and last name, address, city, province, and postal code.

Part 2: Auto Insurer Information

This section includes the Patient’s automotive insurer details. The Applicant (Patient) or Substitute Decision-maker should provide this information. (View screenshot)

Remember: All OCF-23s must be submitted via HCAI. Insurers and Independent Adjusters cannot receive the OCF-23 via fax or mail.

1. Select the insurance company to whom this form will be sent. Use the drop-down list and select from the available companies.

   • Please note: 100% of insurance companies are enrolled and using HCAI. Please be aware that independent adjusting firms will not appear in this drop-down list because they are not licensed insurers. To direct claim forms appropriately, HCFs should determine (typically by asking the patient or the Independent Adjuster) the name of the licensed Insurer that is managing the claim.  

2. Indicate whether the policy holder is the same person as the applicant.

   • If the Patient is the person who holds the insurance policy, select “Yes”.

   • If the Patient is not the policy holder, select “No”. For example, a child who has been injured in an accident would likely have coverage under his parents’ policy. In that case, enter the last name of the policy holder.

3. The last name of the policy holder is mandatory if the policy holder is not the same as the Applicant.

Part 3: Other Insurer Information

1. The Applicant (Patient) or Substitute Decision-maker should inform the Facility if there is other insurance. (View screenshot)

   • Facilities are not responsible for errors or omissions in information provided to them by the Patient or Substitute Decision-maker.

   • The Auto Insurer is not liable for any costs that are payable by any other Insurer.

   • The system used by Auto Insurers requires other insurance plans to be accessed before auto insurance health benefits are accessed.

   • Health benefits may also be available from the Ministry of Health and Long Term Care (MOH) or through an Applicant’s (Patient’s) personal, spousal or parental extended health plan. These extended benefits may pay or partially pay expenses listed in the form.

2. Space is available for two other Insurers in the event that the Applicant is covered by more than one policy (for example, if both the Applicant and the Applicant’s partner or Legal Guardian have extended health benefits).

Part 4: Signature of Initiating Health Practitioner

The Health Practitioner that signs Part 4 must be associated as a Provider with your Facility.  External health practitioners are not permitted to sign Part 4 of the OCF-23.

As per FSRA’s HCAI Guideline, the Health Practitioner’s profession in Part 4 of the OCF-23 must be one of the following:

• Chiropractor

• Dentist

• Nurse Practitioner

• Occupational Therapist

• Physician

• Physiotherapist

Other Provider types, including Unregulated Health Professionals, are not authorized to sign the OCF-23 and will not appear in the drop-down list of names in Part 4.

The health practitioner must review the Treatment and Assessment Plan with the Applicant/Patient and confirm that the treatment proposed is in accordance with the Minor Injury Guideline. (View screenshot)

Name of Provider

1. Using the drop-down menus, select the Health Practitioner from your Facility’s Provider list and their profession (if they have more than one assigned).

   • Please note: Only HPs associated with your Facility as a Provider and whose profession is authorized to sign the OCF-23 will appear. If no HPs of a profession authorized to sign the OCF-23 are associated with your Facility as a Provider, the form cannot be submitted. Click here to learn how to add a Provider to your Facility.

Is the signature on file?

In this section, the HCAI web application displays brief attestation wording. Full consent language is viewable on the paper or PDF versions of the OCF-23 only. Once the OCF-23 is complete, it must be printed, reviewed, and physically signed by the health practitioner and stored onsite at your facility.

1. Select the “Yes” or “No” radio button to indicate that the signature is on file and the OCF-23 has been reviewed by the practitioner. The OCF-23 cannot be submitted unless the answer to this question is “Yes”.

2. Once “Yes” is selected, the Signed Date field will appear. Use the drop-down calendar menu or type in the date of signature (YYYY/MM/DD).

Is the Provider the initiating Health Practitioner?

1. Answer “Yes” or “No” using the radio buttons.

Part 5: Injury and Sequelae Information

Injuries or problems are coded using the standard descriptions from the International Classification of Disease, 10th version, Canadian edition (ICD-10-CA).

Visit the Coding page or watch the Injury Coding Basics video for more information. Furthermore, call your health professional association to find out if they have developed an injury code list specific to your profession.

The purpose of Part 5 is for the HCF to code the complaints, injuries and sequelae that are a direct result of the automobile accident and the most responsible for the services proposed in the plan. (e.g. S42.0 – Fracture of clavicle; Z58 – Problems related to physical environment)

1. Use the HCAI search utility to search for injury/sequelae codes. (View screenshot)

2. List each code only once, regardless of how many Health Professionals will be engaged in treatment.

3. The first line item should reflect the primary reason or problem that is most responsible for the proposed services.

   • Example: If psychological services are required after a brain injury, the first code listed should reflect the reason that psychology services are being proposed. F07.2 – Post-Concessional Syndrome, and then S06 – Concussion.

   • In a case where multiple injuries may be classified as the most significant, list the injury requiring the most services first.

4. An injury that has resolved (e.g., a healed fracture) or a condition that is not responsible for the services in the plan, should be listed last; alternatively, that injury or condition can be relegated to Part 6 “Prior and Concurrent Conditions” (i.e., a resolved problem can be considered a prior problem).

   • Example:  Original injury is S73 – Fractured femur. The surgeon reports that the fracture is healed. The femoral fracture is resolved, but ongoing treatment is required to manage pain and gait re-education. In this case, the problems listed could be:  M79.6 – Pain in limb; and R26 – Abnormalities of gait.

5. To provide the Insurer more information regarding the Applicant’s (Patient’s) injury, problem or circumstances, use the Additional Comments section on the final tab of the form.

Injury/Sequelae Coding for Assessment Proposals

Each assessment proposed is presumed to be required to address a complaint, injury or sequelae

1. Code the complaint, injury or sequela that has led to the requirement for an assessment.

   • Example 1: Patient reports persistent low back pain that is not responding to treatment. Problem may be coded as M54.4 (Low Back Pain)

   • Example 2: Patient is unemployed and vocational evaluation being proposed to facilitate RTW. Problem may be coded Z56 (Unemployment; unspecified).

Questions about coding

If you have questions about which injury code(s) to use, contact your health professional association. HCAI support staff do not have medical training and are unable to offer guidance on any topic other than the use of the HCAI application.

Common codes

• Single physical injury – refer to S codes. (e.g. S42.0 – Fracture of clavicle)

• Multiple injuries and bilateral injuries – refer to T codes (do not list duplicate codes for bilateral injuries).

• Mental and behavioral disorders – refer to F codes.

• Symptoms, signs and abnormal clinical and lab findings not elsewhere classified – refer to R codes.

Adding additional lines for injury/sequelae codes

If more space is required for additional injuries or problem codes, extra lines may be added by clicking the "+" button. (View screenshot)

Part 6: Prior and Concurrent Conditions

This section is to help the Insurer better understand the Applicant’s (Patient’s) condition before the accident. It informs the Insurer of any pre-existing condition(s) that may affect the Patient’s response to treatment, and it provides additional information around circumstances that may affect recovery.

Provide relevant information to the best of your knowledge and based on information supplied by the Applicant (Patient) or Substitute Decision-maker. (View screenshot)

Part 7: Barriers to Recovery

Indicate any barriers to recovery that may affect the success of the treatment.

1. If there are any circumstances or barriers that may affect an Applicant’s recovery, select “Yes.”

2. If you select “Yes”, provide an explanation of the barrier in the text field that appears. (View screenshot)

Part 8: Direct Payment Assignment

This section indicates whether the applicant has initialed to assign direct payment to the licensed service provider.

Only facilities with a valid Service Provider Licence at the time of treatment and invoicing are allowed to be directly paid by the insurer. To learn more visit our Service Provider Licensing page.

1. If your facility holds a valid Service Provider Licence and is to be paid directly by the insurer, review this section with the applicant and select the “Yes” radio button to indicate that they have provided consent.

   • Ensure the Applicant/Patient understands this section before they provide their consent. Applicant consent does not override Service Provider Licensing rules.

2. Once the OCF-23 is completed in HCAI, print the plan and have the Applicant initial the paper copy. Retain this copy for your Facility records.

3. If your Facility is not licensed, select the “No” radio button.

Part 9: Signature of Applicant

This section indicates whether you have secured and saved a paper copy of the form, signed by the applicant or substitute decision maker. (View screenshot)

1. Select “Yes” or “No” to the question “Is the applicant’s or substitute decision maker’s signature on file?” If you select “Yes,” new fields appear.

   • Once the OCF-23 is complete, it must be printed and the paper copy must be signed by the applicant or substitute decision maker. This signed copy must be kept on file at your facility.

2. Insert the name of the person who signed the form and the date the form was signed using the calendar tool.

3. Select “Yes” or “No” in response to the question “Is the applicant’s or substitute decision-maker’s signature waived by the Insurer?”

   • To submit forms via HCAI, the Applicant’s signature must be on file, unless the Insurer has waived the requirement for the Applicant’s signature.

Part 10: Guideline Services

In Part 10, enter the Estimated Fee associated with the Minor Injury Guideline, identify Supplementary Goods and Services (if applicable), and submit Estimated Fees for other pre-approved services. (View screenshot)

Please note: When completing Part 10 on an OCF-23 in which radiology services are proposed, view the MIG Codes document for more information on which specific CCI and Attribute codes should be used in addition to the max fee payable.

1. The first field in Part 10 asks you to “Identify which Guideline is applicable”.  Because the “Minor Injury Guideline (MIG)” is the only available Guideline, it is pre-populated in this field.

2. Enter the "Estimated Fee" for the MIG. There is a maximum fee set out in the FSRA Minor Injury Guideline for pre-approved services. This maximum fee is displayed in the Maximum Fee column. If the “Estimated Fee” entered is greater than the amount listed in the Guideline, Insurers may not pay the excess amount.

3. Enter details of “Supplementary Goods and Services” if applicable, as well as the Estimated Fee. The Supplementary Goods and Services that are available are detailed in the Minor Injury Guideline.

4. Finally, enter any “Other Pre-Approved Services (including radiology)” by using the drop-down menus.

5. Select the number of “Views” for each service using the drop-down menus.

6. Include the Estimated Fee for each service selected.

7. Click the “Calculate” button once all Estimated Fees have been entered to view the “Auto Insurer Total”.

   • If the Estimated Fee of a line item exceeds the Maximum Fee amount, a symbol will appear beside the item and a message will appear at the top of Part 10 advising that the proposed amount exceeds the maximum allowable limit under the FSRA Minor Injury Guideline.

   • You will still be able to submit the OCF-23 if the message displays.

   • The Insurer will see the same message.

Additional Comments

The Additional Comments section allows the facility to offer additional information about the Applicant, their injuries, care, treatment, response to treatment, or anything else that will help the Insurer understand the Applicant story.

1. You can cut and paste plain text—from a Word document, for example—but you cannot copy and paste complex tables, charts, or images.

   • There is a limit of 20,000 characters.

2. If you are sending attachments to the Insurer, check off the box next to “Attachments being sent, if any”. Then use the space to describe the attachment. This tells the adjuster not to adjudicate the form until they have received the documents you are sending.

   • If you’d like to submit an attachment as part of the OCF, you cannot embed it into the OCF. Items like PDF files, Excel files, or Word documents must be faxed or mailed directly to the Insurer.

3. If you’d like to save the OCF as a Draft, you can click “Save”. A yellow bar across the top will indicate that your form has been saved successfully. (View screenshot)

4. If you are ready to submit your OCF, click “Submit”. The successful submission window will appear.

5. A unique HCAI document number is generated. This number can be used to track this form.   Insurance adjusters can also track this form in their system using this document number. (View screenshot)

6. To print the submitted OCF, click the “Print” button. The HCAI document number will be displayed on the printed form.

Create an OCF-23 Template/Draft

If you plan on filling out multiple OCF-23s with similar information, you can save a draft OCF-23 as a template that can be customized in the future. The save as draft feature is also useful if you need to stop in the middle of filling out an OCF and resume at a later time.

To create a draft OCF-23 from scratch:

Please note: If you are currently filling out an OCF-23 but have not yet submitted it, you can use it to create your draft at any time. Skip to step 3 below.

1. To create a draft OCF-23 from scratch, go to the Plans tab and the Work in Progress sub-tab.

2. Create a new OCF-23 by selecting OCF-23 from the drop-down list and clicking “Create new”.

3. In order to save the OCF-23 as a draft, the following fields must be complete (but can be modified after saving):

   • Claim or Policy Number

   • Patient first name

   • Patient last name

4. Click on the “Save” button in the top right or bottom right of the OCF window.

5. A yellow bar will appear on the Form stating, “Document was saved successfully”. You can now exit the OCF.

To use a draft OCF-23:

1. You can access drafts that have been saved by clicking on the Draft sub-tab on the Plans or Invoices main tab. (View screenshot)

2. To open a draft, click on the magnifying glass button to the left of the OCF Type.

3. You may modify any fields as needed and then click “Save” again or submit the OCF. Submitting the OCF will not delete the draft. The draft version will still be available in the Drafts sub-tab for future use.

To delete a draft:

1. Click on the Drafts sub-tab of the Plans or Invoices main tab.

2. Select the checkbox to the left of the draft you wish to delete.

3. Click the “Delete” button at the bottom of the list.

4. Click “Okay” on the pop-up prompt that appears.

Please note: It is best practice to delete any drafts that are older than one year. Drafts older than one year may reflect old versions of forms and may not be able to be submitted.