Claims tools

Documents tab

The Documents tab is where users can review and adjudicate OCFs. The page is divided into two sections: (View screenshot)

• Filters: On the left side, users will see enhanced filtering options that allow them to select what kind of documents display on their worklist. This filter pane can be hidden/restored from view by clicking the double arrows to collapse/restore the pane.

• Worklist: On the right side, users will see the familiar worklist grid, with additional flexible “quick filter” options on top.

Standard filters

The Filters section displays a list of standard filters that users can select to change the type of document that displays on their worklist. Click the name of a standard filter to apply the filter to your worklist. After applying a standard filter, you can further refine the documents that display using the three quick filters at the top of the worklist– claimant file owner, document type, and document status.

Users can set any standard filter as their default so that each time they log in, they immediately see the information they need to complete their most common tasks in HCAI. To set a standard filter as your default filter, click the arrow next to the name of the filter and select “Set as Default”.

The standard filters that are visible to each user will differ according to their roles in HCAI.

All users with worklist access will see the following standard filters:

• My Inbox displays all unadjudicated plans and invoices assigned to the user. “Assigned” means the user is the claimant file owner of the document’s claimant.

• My Plans displays all unadjudicated plans assigned to the user.

• My Invoices displays all unadjudicated invoices assigned to the user.

• My Responses displays all adjudicated documents assigned to the user.

• All Outstanding Documents displays all unadjudicated plans and invoices the user has permission to access. The user is not necessarily the claimant file owner of these documents.

• All Responses (Last 90 Days) displays all plans and invoices that were adjudicated in the last 90 days, and that the user has permission to access. The user is not necessarily the claimant file owner of these documents’ claimants.

Users with the Form Manager role in HCAI will also see the following standard filters:

• Unmatched displays all the unmatched unadjudicated documents the user has permission to access.

• Needs Assignment displays all unadjudicated documents that are matched to claimants that either have no file owner assigned, or need to be re-assigned because the file owner is no longer eligible. Ineligible file owners are deactivated users, do not have permission to have ownership of claimant files, or do not have access to the claim group in which the claim-claimant record resides.

Click on the arrow next to a standard filter’s name to view the following options:

• Apply refreshes your worklist with the filter applied. This has the same effect as clicking on the filter’s name.

• Copy allows you to create a new custom filter with the same criteria as the selected filter. You can edit the criteria if desired and enter a new name. The copy will be saved under “Custom Filters”.

• Set as Default will make this filter your default filter. When you log in and navigate to the Documents tab, your worklist will display the default filter.

Custom filters

Users can expand or narrow their worklist even further by creating custom filters, and these custom filters remain available for repeated use. Each user can save up to twenty custom filters. Custom filters can be edited and deleted as needed. Custom filters cannot be set as your default filter.

Users can filter using various combinations of insurer, branch/claim group, team, claimant file owner, document type and status, matched status, number of days left to respond, date responded, and adjudicating user. For example, if you are covering for a colleague and wish to review plans recently adjudicated by that colleague, you could create a custom filter that will display all adjudicated plans according to the adjudicating user or the date responded, in a single worklist. 

To create a custom filter:

1. In the Filters section of the Documents tab, click the “Create New Filter” button. (View screenshot)

2. The “New Filter” screen appears. Input filter criteria.

3. Click “Preview” if you would like to preview your worklist with the custom filter applied.

4. Click “Save Filter” to save the custom filter for future use.

5. Enter a name for the custom filter and click “Save”. The custom filter is now accessible on the Filters menu under the “Custom Filters” subheading.

Click on the arrow next to a custom filter to view the following options:

• Apply refreshes your worklist with the custom filter applied. This has the same effect as clicking on the filter’s name.

• Copy creates an additional copy of the custom filter, allowing you to edit the criteria if desired and enter a new name.

• Edit allows you to change the custom filter’s criteria.

• Rename allows you to change the filter’s name.

• Delete will remove the filter from your custom filter list.

Please note: In the future, if you attempt to apply a custom filter that is now obsolete, the results will not display on your worklist. Instead, you will see the following error message: “The filter that you are trying to use has become obsolete. You may edit the filter to revise it or delete the filter.”

Target Date

The Target Date is a handy column that is displayed on the Documents tab worklists and Document Search Results screen to help form adjusters and support staff manage their workload based on the timelines set out in the Statutory Accident Benefits Schedule (SABS).

The Target Date is calculated when an OCF is submitted by a health care facility. The Target Date recognizes the end of day as 5:00 p.m. (EST). Any OCF received after 5:00 p.m. (EST) is deemed by the system to have been received the next business day (for plans) or calendar day (for invoices). This will be automatically accounted for in the Target Date.

The Target Date is calculated based on the timelines set out in the SABS: 30 calendar days for invoices, 10 business days for the OCF-18 and Form 1, and 5 business days for the OCF-23. Business days are Monday to Friday and do not include Saturdays and public holidays. For a complete list of public holidays, please view our Statutory Holidays page.

Health care facilities do not have a Target Date in their list of submitted documents; however, a facility may follow up with an insurer if a plan sits in a submitted state for a prolonged period of time without any change in the form’s status.

Claimant Summary report

The Claimant Summary report is available to all adjusters and users with the Report Viewer role.

What is it?

The Claimant Summary report is a decision-support tool that summarizes injuries, goods and services, costs and duration of treatment for an individual claimant. Cost and count totals are drawn from adjudicated Form 1s, OCF-18s, OCF-23s, OCF-21Bs and OCF-21Cs.

This report does not contain archived OCFs.

How do I access the Claimant Summary report?

1. Take note of the claim number you wish to run the report for

2. Go to the Manage tab > Reports subtab

3. Under the ‘Generate New Report’ section, select the ‘Claimant Summary’ report, select the relevant insurer and enter the claim number you wish to obtain the report for

4. Press the “Get Claimants” button (View Screenshot)

5. The screen will refresh and the ‘Select a Claimant’ section will appear. Select the claimant you wish to run the report for using the drop down menu

6. Press the ‘Generate Report’ button. The screen refreshes and confirms that the request was received

7. The report may take some time to process. Once it is ready to review, the Report Name will appear as a hyperlink under the ‘Reports Requested’ section, click it to open the report (View Screenshot)

8. To view the goods and services section of the report as a .CSV file, press the ‘Download Amounts’ button at the top of the report to download the files (View Screenshot)

 You can leave the report as-is, or you can add in paid amounts from outside of HCAI

Claimant Financial Summary

The Claimant Financial Summary provides a summary of the amounts proposed and approved for a particular claimant. To view the report, you will need the Form Manager, Form Adjuster, Claim-Claimant Editor, or Claim-Claimant Administrator role in HCAI.

The report is found on the Claimants Search Results screen. You can access the Claimants Search Results screen two ways:

• On your Dashboard, click a section of the Claimant Summary pie chart. This performs a search for claimants based on the pie chart’s criteria. (View screenshot)

• Visit the Claims tab > Claimants sub-tab and perform a search for claimants. (View screenshot)

On the Claimants Search Results screen, the far right column is titled Financial Summary. Click ‘View Report’ to view the Claimant Financial Summary for this claimant. The report opens in a new window. (View screenshot)

To download the Claimant Financial Summary as a .CSV file, click the ‘Download Report’ button at the top right of the window. This will allow you to save and edit the information as required – for example, you can use Excel to calculate balances, sort documents by different criteria, or add billing that occurred outside of HCAI. (View screenshot)

The Claimant Financial Summary web view is broken down into separate sections for each OCF type. A maximum of ten documents per section is displayed at a time. If you have more than ten documents in a section, you can press the ‘Next’ hyperlink to see more documents.

Each OCF section will display the following columns (View screenshot):

• Document number: Click on the Document number to open that document in a new window.

• Plan #: Visible in invoice sections only, the Plan # column displays the associated plan number. If the invoice is not associated with a plan, the column will state ‘Exempt’. If the link between the invoice and plan has been broken, a dash will appear. This can occur if the plan and invoice are matched to different claimants.

• Facility: Click on the Facility name to open a new window that displays the signing provider’s details, including name, professional details, billing address and service address.

• Status of the document

• Proposed Amount

• Approved Amount: This column will appear in all OCF sections except the OCF-23

• Pre-Approved Amount: In the OCF-23 section, you will see the Pre-Approved Amount column, which is sub-divided into two columns: Declined and Responded.

At the bottom of each OCF-type section, you will see the following total amounts:

• Non-archived Sub-total: The sub-total of proposed and approved amounts of all non-archived documents

• Archived sub-total: The sub-total of proposed and approved amounts on archived documents. Archived documents won’t display in the lists, but the total is included for your reference. If none of the claimant’s documents have been archived, the archived amount will be blank.

• Total (including taxes): The total proposed and approved amounts, including archived documents and taxes.

• Tax Amount: Here, taxes are displayed separately. This line will display in the OCF-18, OCF-21B, and OCF-21C sections.

For users who do not have the Form Manager, Claim-Claimant Editor, or Claim-Claimant Administrator role in HCAI, similar information is available in the Associated Documents section of each OCF.

Associated Documents section

The ‘Associated Documents’ section is available on the decision-making tab of all forms in the HCAI web application. It does not appear on the printed/PDF version of OCFs. To view the Associated Documents section, open an OCF and navigate to the Associated Documents Results section.  Click the ‘View Associated Documents’ button. (View screenshot)

To download the Associated Documents section as a .CSV file, click the ‘Download Report’ button at the top right of the section. This will allow you to save and edit the information as required – for example, you can use Excel to calculate balances, sort documents by different criteria, or add billing that occurred outside of HCAI. (View screenshot)

The Associated Documents section offers two viewing options: Claimant View (default) and Plan View. Use the ‘View’ drop-down in the top right corner of the section to select a view. (View screenshot)

• Claimant View: Displays a consolidated view of a claimant’s plans and invoices in HCAI.

• Plan View: Displays all documents associated with the current plan that are matched to the same claimant.

  • If you are reviewing an invoice, this view will display the parent plan and all its associated invoices.

  • If you are reviewing a plan, this view will display the plan and its associated invoices. Please note: there are no invoices associated to the Form 1 in HCAI.

In both views, the Associated Documents display is broken down into separate sections for each OCF type. A maximum of ten documents per section is displayed at a time. If you have more than ten documents in a section, you can press the ‘Next’ button to see more documents.

Each OCF section will display the following columns (View screenshot):

• Document number: Click on the Document number to open that document in a new window.

• Plan #: Visible in invoice sections only, the Plan # column displays the associated plan number. If the invoice is not associated with a plan, the column will state ‘Exempt’. If the link between the invoice and plan has been broken, a dash will appear. This can occur if the plan and invoice are matched to different claimants.

• Facility: Click on the Facility name to open a new window that displays the signing provider’s details, including name, professional details, billing address and service address.

• Status of the document

• Proposed Amount

• Approved Amount: This column will appear in all OCF sections except the OCF-23

• Pre-Approved Amount: In the OCF-23 section, you will see the Pre-Approved Amount column, which is sub-divided into two columns: Declined and Responded.

At the bottom of each OCF-type section, you will see the following total amounts:

• Non-archived Sub-total: The sub-total of proposed and approved amounts of all non-archived documents

• Archived sub-total: The sub-total of proposed and approved amounts on archived documents. Archived documents won’t display in the lists, but the total is included for your reference. If none of the claimant’s documents have been archived, the archived amount will be blank.

• Total (including taxes): The total proposed and approved amounts, including archived documents and taxes.

• Tax Amount: Here, taxes are displayed separately. This line will display in the OCF-18, OCF-21B, and OCF-21C sections.

Document search

HCAI allows you to quickly launch a search from your worklist screen. Simply enter a claim number into the ‘Search for Claim Number’ search bar and press ‘Go’, or press the ‘Advanced’ button to go directly to the OCF Search screen (View Screenshot). You can also go directly to the ‘Search’ global tab at any time (View Screenshot) to navigate to the exact same screen.

On the OCF Search screen, enter your specific search criteria and press ‘Search’. The more information you enter into your search query, the faster HCAI will execute the search.

Clicking the ‘Advanced Options’ link at the bottom right-hand corner of the Document Search screen (View Screenshot) will provide you with additional search parameters. These additional parameters include:

• Document Type (e.g. OCF-18, OCF-21B, OCF-21C, OCF-22, OCF-23, Form 1)

• Document Status (e.g. Submitted, Approved, Declined, etc.)

• Claimant Status (e.g. Active, Deactivated, Not Matched)

• Days Left to Respond (From/To, Overdue, Days Left Not Tracked Payable to Claimant, Days Left Not Tracked Response Withdrawn)

• Matched to Claimant (Matched and Correctly Assigned, Matched but Needs Reassignment, Matched but Not Assigned, Not Matched)

• Date Responded (From/To)

• Adjudicating User

• Archival Status (Archived, Not Archived)

• Provider Information (Provider name, Profession, Registry Number)

• Facility name

Once you enter your search criteria and press the ‘Search’ button, you will be brought to the search results screen. HCAI sorts the search results according to the date the document was submitted. The most recent results appear first. There are also options to open the PDF version of each document, download the results in CSV format or refine the search. Up to 100 search results can be viewed at a time. (View screenshot)

If you are expecting to see a search result and it’s not there, re-check your search criteria and perform the search again. If it still does not appear, escalate the issue to an administrator who can search for the form across the entire organization. For more information, please visit the Can’t Find an OCF? page.