Track My OCF

HCAI provides a confirmation message once an OCF has been successfully submitted. The message states “You have submitted document number…” This unique number can be used to track your OCF (View screenshot).

On the Work in Progress sub-tab, each OCF is assigned a status. The following list describes what is meant by each status that the HCAI system assigns to an OCF:

• Submitted – The plan has been submitted but not yet reviewed.

• Review Required – The Insurer has opened the OCF.

• In Discussion – The Adjuster has posed a question for the Facility that submitted the form.

• In Discussion; Response Sent – the Facility has replied to the Adjuster’s question

OCFs submitted via HCAI are subject to the Statutory Accident Benefits Schedule (SABS). HCAI is not responsible for enforcing the SABS timelines.

If you have submitted an OCF and it has not been adjudicated within the SABS published timeline, contact your Patient’s Adjuster/Insurer.

Use the Search tab find an OCF that meets specific criteria. The search is done on submitted OCFs only—draft OCFs are excluded (View screenshot).

1. Click the checkbox next to the search criteria value to generate only an exact match. When the “Exact Match” box is checked off, the search results will be identical to the criteria entered. When “Exact Match” is unchecked, forms with similar criteria will be displayed.

2. Click “Advanced Options” at the bottom of the Search screen to search by document type, adjudication status, or archival status.

3. Click search to find the OCF you are looking for. If there is more than one search result, the results will be arranged by the date they were submitted, with the most recent result appearing at the top.

4. Use the “View” drop down on the top right of the Search Results box to change how many items display on the page.

To download your search results, click the “Download Report” button on the top right of the Search Results box. This allows you to save the results as a .CSV file, viewable in spreadsheet software. Your software settings will determine how the data is displayed.  

Downloading the report will allow you to view information about multiple documents at once, including the date each document was submitted alongside the date it was last modified.

• Please note: Only the results currently displayed on the page will be included in this report. Use the “View” drop down to display up to 100 items per page. If the document search generated more than 100 items, navigate to the next page to download a report of the additional items.

Use the Search tab to search for an archived OCF.  The search is done on submitted OCFs only (draft OCFs are excluded).

1. Click “Advanced Options” at the bottom of the Search screen.

2. Beside Archival Status, select the “Archived” button to search for an archived OCF. You may fill in any other search criteria to narrow your search (View screenshot).

3. Click search to find the OCF you are looking for. If there is more than one search result, the results will be arranged by the date they were submitted, with the most recent result appearing at the top.

4. Use the “View” drop down on the top right of the Search Results box to change how many items display on the page.

To download your search results, click the “Download Report” button on the top right of the Search Results box. This allows you to save the results as a .CSV file, viewable in spreadsheet software. Your software settings will determine how the data is displayed.

• Please note: Only the results currently displayed on the page will be included in this report. Use the “View” drop down to display up to 100 items per page. If the document search generated more than 100 items, navigate to the next page to download a report of the additional items.

1. From the Adjuster Response tab, click on the magnifying glass button next to the OCF you want to open (View screenshot).

2. The first page you will see on the OCF is the Summary page. It provides an overview of the OCF and also displays the OCF’s message log and current state.

3. In the Part 3: Plan/Invoice Details section you will see:   

   • Document Number: This is a system-generated number unique to the form.

   • Owner: This field displays the name of any Adjuster who is currently working on the plan.

   • Status:

     • Approved – The Adjuster has approved all the goods and services proposed under the form.

     • Partially Approved – The Adjuster has approved only some of the goods and services proposed under the form.

     • Declined – The Adjuster has not approved any of the goods or services proposed under the form.

     • Responded – This status is only available on the OCF-23 and indicates that the Applicant (Patient) has a valid policy of insurance in force. The OCF-23 is a claim for “pre-approved” services, so the Adjuster cannot “Approve” an OCF-23.

Reviewing the adjudicated form

Each Tab of an adjudicated OCF contains read-only details presented in the same order as they were entered. Navigate through the plan by using the numbered tabs.

The following sections contain changes or response details from the Insurer:

• Part 1: Applicant Information. The Applicant (Patient) details provided in the initial plan are linked to the Insurer claimant details. You can see both in this section.

• Part 2: Auto Insurer Information. The Applicant (Patient) details provided in the initial plan are displayed.

• Totalling: This section contains Proposed amount submitted next to the Approved amount as recorded by the Adjuster.

• Signature of Insurer/Adjuster Details: This contains the Adjuster’s first and last name and the date the OCF was responded on.

The Part(s) of each OCF that list the proposed goods and/or services contain the Adjuster’s decision per service.

Review Adjuster Responses on each OCF in the following places:

• Form 1: Part 1, Part 2, Part 3, and Part 4

• OCF-18: Part 12

• OCF-21B: Reimbursable Goods and Services,

• OCF-21C: Reimbursable Fees within the Minor Injury Guideline, and Other Insurance

Once an OCF is adjudicated in HCAI, it is assigned a status:

Approved – the Insurer has approved all aspects of the submitted document.

Partially Approved – the Insurer has approved some of the items requested on the plan or invoice. When the Facility opens the adjudicated plan/invoice, the Facility will be able to view the Adjuster’s reason code beside the good and service and additional details in the ‘Explanation of adjuster response’ box explaining why the decision was made, if the Adjuster has provided details.

Declined – the Insurer has declined the items requested on the plan or invoice. In these cases, the Insurer may notify the Applicant (Patient) of the decision via an Explanation of Benefits form  and also will notify Applicant (Patient) of the next steps. When the Facility opens the adjudicated plan/invoice, the Facility will be able to see the reason for the Adjuster’s decision.

Responded – this response is specific to the OCF-23 and indicates that the Applicant (Patient) has a valid policy of insurance in force.   This is because the OCF-23 is a claim for “pre-approved” services. For this reason, the Adjuster cannot “Approve” an OCF-23. However, any goods and services delivered to Applicant (Patient) within the MIG framework are still subject to adjudication.

Once a plan or invoice has been adjudicated, Facilities may open the plan or invoice to determine why the plan was declined or partially approved.

1. Go to the Plans or Invoices global tab (depending on whether you are looking for an adjudicated plan or invoice).

2. Go to the Adjuster Response tab.

3. Locate the plan/invoice you want to open.

4. Click on the Review Form button  at the left of the window to open the plan or invoice.

5. The Part(s) of each OCF that list the proposed goods and/or services contain the Adjuster’s decision per service (View screenshot).

For all services not approved, the Adjuster must provide an Adjuster Response code and explanation. These are summarized in the Adjudication Reason Codes (PDF).

If you require more information about why a good or service was declined, contact the Adjuster or speak with the Applicant/Patient who will have received an explanation of benefits notice from the Insurer.

The Explanation of Benefits form (EOB), formerly known as the OCF- 9 is a statement sent to the claimant from their insurer explaining what medical treatments and/or services will be paid (or not) for on their behalf.

The EOB can be generated in HCAI by an adjuster after recording a decision against a submitted OCF document.

The adjuster provides a printed copy of the EOB to the claimant. They can also choose to submit the EOB via HCAI, which will make it available to be viewed by the facility that submitted the OCF.

If an EOB has been sent, an icon will appear on the Adjuster Response tab in HCAI, next to the OCF type column (View screenshot).

To view the EOB:

1. Click on the magnifying glass button to open the OCF.

2. Click on the “View EOB” button on the OCF summary tab. The EOB opens in a new window.

3. To view the adjudication decision, click on tab 2 of the EOB.

4. The “Medical and Rehabilitation and Other Benefits” included in Part 4 of the OCF are listed.

5. The “Reason why expenses are not payable or being stopped” section includes the adjudication reason codes and the corresponding explanation for each code.

Please note: The Safety, Licensing Appeals and Standards Tribunal Ontario (SLASTO) has assumed all new applications for dispute resolution from the Financial Services Commission of Ontario. To streamline the user viewing experience on HCAI, Tab 3, which used to contain the Applicant’s Rights to Dispute, will be hidden from the web view. The new wording will be displayed on the paper or PDF versions of the EOB only.

To create a Draft OCF:

When an OCF is created, it can be saved as a draft by clicking the “Save” button. A yellow bar will appear to indicate you have successfully saved the draft. You are then free to exit the OCF (View screenshot).

In order to save an OCF as a draft, the following fields must be completed (but can be modified in the future):

• Claim or Policy Number

• Patient First Name

• Patient Last Name

You can then access your draft by clicking the Draft sub-tab from the Plans or Invoices tab.

To delete a Draft OCF:

1. Click on the Draft sub-tab within the Plans tab.

2. You can click on “Date Modified” to sort drafts from oldest to newest if desired. Date Modified is the date the document was last modified. Every time an OCF in the Draft tab is changed or updated and these modifications are saved, HCAI records the date the modifications occurred.

3. Use the checkboxes on the left side to select the drafts you wish to delete. You may select more than one draft to delete.

4. Click on the Delete button.

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

OCFs that have been saved automatically go to the Draft folder.

If you saved an OCF and cannot find it, make sure you are looking in the correct global tab – Plans or Invoices.