Form Overview
All about the OCFs that are available in HCAI.
Forms available in HCAI
The Financial Services Commission of Ontario (FSCO)* produces Ontario Claims Forms (OCFs) to enable stakeholders to access services provided in each regulated sector. The OCFs available on HCAI provide details on a Claimant’s injuries, recommend and advise on treatment and provide invoice details for payment of health care services.
*Please note: Effective June 8, 2019, the Financial Services Regulatory Authority (FSRA) assumed the regulatory functions of the Financial Services Commission of Ontario (FSCO). Visit www.fsrao.ca for updates.
You can choose to review a submitted form as a PDF or on the HCAI application, but adjudication decisions are always made within the HCAI application. The HCAI application was designed to mirror, as closely as possible, the layout of the paper OCFs.
OCF-18 Treatment Plan
The OCF-18 or the Treatment and Assessment Plan, describes the cause and nature of injuries that are a direct result of the motor vehicle accident. It outlines assessments, or examinations that a Health Care Facility or associated provider feels are required for ongoing management of the claimant’s recovery.
The OCF-18 also identifies activities limited by the injury, sequelae, defines treatment plan goals, barriers to recovery, identifies the claimant’s prior and concurrent conditions that could affect the response to treatment and proposes a treatment plan including cost estimates to address the injuries.
Except for treatment provided under the Minor Injury Guideline, or where the Insurer has waived the requirement for a treatment plan, facilities must complete an OCF-18 in order to have a plan of treatment approved and funded by an insurer.
The OCF-18 in HCAI
In HCAI, OCF-18s can be found in the ‘Plans’ tab. There are seven tabs: the Summary page, and six tabs completed by the facility. Only two of the six Tabs require any action or response: Tab 1 (where claimant and adjuster information can be updated) and Tab 5, where decisions are recorded.
OCF-23 Treatment and Confirmation Form
The OCF-23, or Treatment Confirmation Form, is the form used by a facility and/or associated provider to inform an insurer that treatment for an injured person will commence within the Minor Injury Guideline (MIG). If an insurer confirms that the injured person has a valid policy, treatment in the OCF-23 does not require prior insurer approval.
A facility must complete and submit an OCF-23 in order to establish his or her right to reimbursement for the delivery of MIG treatment.
The OCF-23 in HCAI
In HCAI, OCF-23s can be found in the ‘Plans’ tab. There are five tabs: the Summary screen and four tabs completed by the facility. Only two of the five Tabs require any action or response: Tab 1 (where claimant and adjuster information can be updated) and Tab 4, where decisions are recorded.
Form 1 Assessment of Attendant Care Needs Form
The Form 1 (also known as the Assessment of Attendant Care Needs) is used by an assessor to report the future needs for attendant care required by the applicant as a result of an auto accident. This form must be completed by a member of a health profession who is authorized by law to complete the form.
The Form 1 in HCAI
In HCAI, the Form 1 can be found in the ‘Plans’ tab. There are eight tabs: the summary tab and seven tabs completed by the facility. Adjusters have flexibility with respect to how they mark their decision on the document: they can adjudicate at the form level, at the section/page level, or at the item level. For this reason, there are many Tabs that can accept adjudication input from the adjuster.
OCF-21 Automobile Insurance Standard Invoice
The OCF-21 is used to invoice automobile insurers for the medical and rehabilitation goods and services, assessments and examinations submitted under the OCF-18 and OCF-23 forms. It was devised to provide more efficient processing of invoices, better information about medical and rehabilitation health services and to increase accountability.
Any facility billing an Ontario auto insurer to treat a victim of a motor vehicle accident under the Statutory Accident Benefits Schedule (SABS) of the Insurance Act should use this form.
The OCF-21 in HCAI
Both the OCF-21B and OCF-21C can be found in the ‘Invoices’ tab. Both contain 5 tabs. On the OCF-21B, only three tabs require any action or response: Tab 1 (where claimant and adjuster information can be updated), Tab 2 (where line items are adjudicated) and Tab 3 (where decisions are recorded). On the OCF-21C, only two tabs require any action or response: Tab 1 (where claimant and adjuster information can be updated) and Tab 3 (where decisions are recorded).
Explanation of Benefits (formerly OCF-9)
The Explanation of Benefits (EOB) is designed to be used to notify claimants which benefits are approved and the amounts payable. HCAI allows you to create an EOB on an adjudicated form. Where a benefit has not been approved, an explanation is provided. If a claimant disagrees with an insurer assessment, Part 6 of HCAI’s EOB PDF outlines the applicant’s rights to dispute and provides a link to the Licence Appeal Tribunal website where instructions for filing an application can be found.
The Explanation of Benefits (EOB) can be generated and viewed only after a decision has been recorded on a plan or invoice.
To generate an EOB:
Open the plan or invoice you wish to generate an EOB for
Click ‘Create EOB’ at the top or bottom of any of the tabs
The window refreshes and the ‘Create EOB’ screen opens to Tab 1. Tab 1 contains information about the plan or invoice that is read only and cannot be updated (View Screenshot)
Once you have finished reviewing the information on Tab 1, continue to Tab 2. This tab contains additional information about the plan/invoice, including a column for adding interest payable (View Screenshot)
To save an EOB, click ‘Save’. This saves the document as a draft. It will not be viewable to the facility
At this point, you can decide to prepare the EOB for a claimant, or you can share the EOB with the submitting facility. These steps are detailed below
To prepare the EOB for a claimant:
Click ‘Print’ to produce a PDF of the form to be shared with the Claimant
To share the EOB with the submitting facility:
An adjuster may wish to provide additional details about their decision by submitting an EOB to the submitting health care facility.
Click the ‘Submit’ button at the top or bottom of the EOB
Review the information in the EOB and click ‘Confirm’
A window will appear to confirm the EOB has been submitted to the facility
