OCF-21B: Creating invoice from scratch
Contents
1. 0 Health Claims for Auto Insurance OCF 21B CREATE INVOICE FROM SCRATCH MANUAL FOR WEB USERS July 2012 Table of Contents WHEN DO I USE AN OCF 21B WHAT IS INCLUDED IN THIS MANUAL 1 4 1 WHERE CAN GET MORE INFORMATION isses nnne tnn EXAMPLES OF COMPLETED SECTIONS OF THE FORMS o e Fe ort OCF 21B CREATE INVOICE FROM SCRATCH E WHO COMPLETES THIS FORM PREPARE FOR SUBMISSION TO THE INSURER WHAT IS THE INSURER S 5 2525 0 COMPLETION OF AN OCF 21B IN 111 Wi c PART APPLICANT ba VET Ek RUE diekin PART 2 AUTO INSURER INFORMATION ccccececececececcacacececececcacacacecececeeaeacsceseeauavacsuenes al BB ome ID E PART 4 PAYEE INFORMATION INJURY AND SEQUELAE CODES REIMBURSABLE2. therefore GAP codes were developed specifically for Ontario s auto insurance sector o GAP codes can be used for services that are not well reflected in the CCI Assessments including e Administrative services such as travel time and mileage examination Goods and Supplies e Health Provider Initiated Examination amp Insurer Initiated Examination including o Attendant care o Catastrophic o Disability Pre 104 weeks and Post 104 weeks o Combined MedRehab and Disability MedRehab e Session Codes e Telephone consultation with other Health Care Providers 248 Attribute In addition to the CCI code health care services can be further specified with Attribute Codes These codes are used to indicate how the service was delivered or for example the number of views in an X ray study Provider reference Use the dropdown list to select the Health Care Provider who delivered care on a given date 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 Insert one Health Care Provider for multiple line items There is a shortcut for inserting one Health Care Provider name in multiple line items as follows 1 Complete all fields except for the Provider Ref fields 2 Tick each box to the left of the each completed line item 3 Click APPLY PROVIDERS Select the name of the Health Care Provide
3. GOODS AND SERVICES 40 0000 anana n nna PRIOR BALANCE OVERDUE AMOUNTS AND INTEREST CHARGES OTHER INSURER INFORMATION 0 0 010 01 CHARGED SERVICES SERVICES CHARGED TO OTHER TO ALNG CO C M lel que e a 4 4 EEES a 5 5 ADDITIONAL COMMENTS 19 HOW KNOW MY FORM HAS BEEN SUBMITTED 19 WHAT IF MY FORM HAS NOT BEEN SUCCESSFULLY SUBMITTED 20 When Use an OCF 21B An OCF 21B is used when invoicing for goods and services delivered to Claimants with the exception of services delivered in the Minor Injury Guideline MIG for accidents on or after Sept 1 2010 or the Pre Approved Framework PAF for accidents prior to Sept 1 2010 For MIG or PAF invoicing use the OCF 21C For all other invoicing use the OCF 21B What Is Included in This Manual This manual provides detailed instructions for completion of an OCF 21B using the HCAI Web application Where can get more information This manual is updated from time to time The latest updates to the manual can be downloaded from www hcaiinfo ca Contact your Health Professional Association with any questions rela
4. appropriately the Facility should determine typically by asking the patient or the independent Adjuster the name of the licensed Insurer that insures the patient Insurers that use independent Adjusters IAs are able to give IAs access to so they can view and adjudicate the Claimant OCFs for which they have been authorized 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 lf 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 The Substitute Decisions Act states that a substitute decision maker is a person with power of attorney for personal care or a court appointed guardian 8 TAB 2 Part 3 Invoice Details Figure 4 Invoice Details Part 3 Invoice Details To aid in the decision making process please identify the plan for this claimant that is associated with this invoice and whether or not this is the first or last invoice under this plan Provider Invoice Number Firstinvoice no Yes Lastinvoice No Yes Previously Approved Goods and Services For previously approved goods and services please complete the following this invoice for goods and services _ 7 9 Yes approved on an OCF 18 in x P
5. form Once the Insurer matches the form to the Claimant the Insurer will be able to adjudicate the form At that point the form will continue to appear in the Invoices Work in Progress worklist however it will appear in the In Review state After the form is adjudicated the adjudicated form will move to the Invoices Adjuster Response tab where it can be viewed online and or printed There is no fee payable for completion of the standard Invoice Completion of an OCF 21B in HCAI Figure 1 Invoices global tab AVFacility Hc RI 4 EA R H i B T 1 User Manual co LOGOUT WORE IN FPREOKRESS ADJUSTER RESPONSE FE NDING Invoice Management Draft a aveis CREATE NEW Go to the Invoices tab and any sub tab see Figure 1 Select OCF 21B from the dropdown list and click 32535248 A blank OCF 21B will open OCF 21B TABS The OCF 21B in HCAI is organized under five tabs Figure 2 OCF 21 B tabs Create OCF 71B aoe bw E w zs S a 3 7 i gt E M al e Qu 12514 5 aus p 2 User Manual ots a dan rd 1 4282 4 i aT E REEL ZEE DELETE 1 CANCEL PRINT f SAVE Tab 1 Claim Identifier Invoice Identifier Part 1 Applicant Patient Information Part 2 Auto Insurer Information Tab 2 Part 3 Invoice details Part 4 Payee Information pre popula
6. sources Note Amounts for services that have been paid or are estimated to be payable by other insurance sources must be entered with a negative sign preceding the dollar amount 1 Categorize amounts by chiropractic physiotherapy massage therapy and other When the category Other is used specify the type of services covered e g dental psychological optometric 2 Amounts may be signed or unsigned a lf amounts are payable by another Insurer collateral source or the Applicant use negative sign These amounts will be deducted from the amount owed by the auto Insurer b For amounts previously identified for payment by another Insurer but subsequently ruled ineligible use a plus sign or leave unsigned These amounts will be added to the sub total automatically 247 Totalling There are 9 lines in this section It is possible to bill for amounts greater or less than those proposed on Plan but the Insurer may request an explanation Lines 1 2 and 3 are populated by using the information entered in the previous tab o Sub total sum of the cost of all goods and services included on all pages of this Invoice o Minus MOH sum of all Ministry of Health and Long Term Care amounts This amount is taken from the Charged Services MOH line Amounts paid to you or expected to be paid to you are subtracted from the amount billed to the auto Insurer Amounts that you previously stat
7. 0 characters are allowed here If more space is needed use 5 Figure 13 Additional Information 5 Additional Information Make cheque payable to Acme Rehab Other Information 18 TAB 5 Additional Comments Figure 14 Additional Comments and attachments Additional Comments How do complete Additional Comments enables HCFs to Provide more information to Adjusters by using the space given in Tab 5 Advise Adjusters that additional documentation attachments the Insurer requires to adjudicate the form is being sent How should attachments be sent Attachments must be faxed mailed directly to the Adjuster Attachments cannot be sent electronically and should be sent to HCAI indicate that an attachment is being sent to the Adjuster check off Attachments being sent if any When this box is checked use the space below to describe the attachment being sent HCAI enables HCFs 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 that the Insurer will need to adjudicate the form Attachments cannot be sent electronically and must be faxed mailed to the Adjuster To indicate an attachment is being sent to the Adjuster tick the box beside Attachments being sent if any Figure 14 If this box is ticked the
8. D 10 CA codes are not profession specific o The use of ICD 10 CA codes is intended to convey problems and is not necessarily the equivalent of communicating a diagnosis 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 list the problem that is most responsible for the services on the Plan In other words it should reflect the primary reason you are proposing services with the most significant injury first i e the patient s most significant condition that is directly related to the automobile accident and that requires health care services o Example f psychological services are required after a brain injury the first code listed should reflect the reason that psychology services are being proposed e F07 2 Postconcussional Syndrome 506 Concussion In a case where multiple injuries may be classified as the most significant list the injury requiring the most services first ET If an injury has resolved e g a healed fracture or is not the condition most responsible for the services in the Plan list that problem injury last alternatively that problem can be relegated to Part 8 Prior and Concurrent Conditions 1 a resolved problem can be considered a pr
9. Information When the HCF was registered with HCAI the clinic will have chosen Yes or No in response to the question Lock Payables O O Figure 5 Payee Information Part 4 Payee Information the HCF selected Yes the field next to Make Cheque Payable to will be pre populated the HCF selected No the field next to Make Cheque Payable to may be changed Facility Name AISI Facility Number Make Cheque Payable To Payee First Name Payee Last Name Payee Number Address 1 Address 2 City Province Postal Code Phone Fax E mail Sara Codez 45444 Payment 34 toronto street toronto ontario Sara Miller 33 Toronto st west update facility Toronto Ontario uri3e4 416 999 6666 zmillergpibc ca The authorized submitter certifies that the information provided is true and correct He she understand that it is an offence under the Insurance Act to knowingly make a fake or misleading statement or representation to an insurer under a contract of insurance He she further understand that it is an offence under the federal Criminal Code for anyone by deceit faleehood 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 goods and Services that are provided to automobile accident victims by healthcare providers and detecting
10. and preventing fraud Note Authorized signatures obtained during registration 10 TAB 3 Injury and Sequelae Codes Invoices created to bill for services proposed on an OCF 18 Enter the appropriate injury and sequelae codes for the problems for which treatment is being invoiced Invoicing for assessment services lf invoicing for assessment services enter the injury problem code s most appropriate for the Claimant based on the assessment findings lf invoicing prior to the assessment s completion and no impairment has yet been identified code the problem that instigated the assessment O Example An OCF 18 assessment proposal was generated because there was a question about the degree of Health Care Provider dependency The ICD 10 CA code would be 274 problems related to Health Care Provider dependency Example An OCF 18 assessment proposal was generated due to an ongoing pain in the absence of abnormal physical findings The ICD 10 CA code might be R52 9 pain unspecified To learn how to search for injury codes refer to the HCAI Web User Manual which can be accessed on any web page by clicking 111188 Questions about coding Refer any questions regarding injury coding to your Health Professional Association or access the website at www hcaiinfo ca ICD 10 CA codes may reflect a diagnosis condition problem or circumstance that is responsible for the services being proposed o IC
11. ce The previous Invoice is still effective and amounts from prior Invoices should not be added to new Invoices TAB 4 Other Insurer Information Figure 12 Other Insurer Information Other Insurer Information Please provide details for other insurer coverage where applicable have made reasonable enquiries of the claimant and have determined that Q There is no other insurance coverage Yes There is other insurance coverage that is potentially available to cover partially cover these goods and services there Ministry of Health and Long Term Care coverage for goods and services included in this form ONo Q ves Applicable Other Insurer 1 Please provide details for other insurer coverage where applicable Other Insurer Name Plan Or Policy Number f 1 Last Name of Plan Member FirstName of Plan Member Other Insurers Identifier Other Insurer 2 provide details for other insurer coverage where applicable Other Insurer Name Policy Number Last of Member First Name of Plan Member Other Insurers identifier 0000 Select Yes or No to establish whether there is other insurance coverage If yes o Enter the information underneath Other Insurer 1 and if applicable Other Insurer 2 o These fields are NOT mandatory if you do not have the information Charged services services charged to other
12. e field under the Cost column o While HCFs may charge fees in excess of the Superintendent s Professional Fee Guideline Insurers are not required to pay fees that exceed that Guideline 14 Calculate Costs From Rates This functionality is explained in Chapter 5 of the User Manual Calculating Tax If Tax is applicable to a line item check the box in the Proposed Tax column Tick the box to the right of any line item to which you want to add tax Reimbursable Gerds and Services enter the goods and services rendered and the 9 niormation requested To transfer codes from the pian Apply Codes irom Plan Use tee bubons on each ine tem access support delete s ine dem select its check and Deleie Mefar io the weer manual at yoy ca for coding nformalion Atinbub codes are described n fhe manual 1 app amp es good e service check ihe Tax checkbox on ihal ine tem Daie 5erunces Code Proweler Reference Quantity Measure Cost 201200601 H Xx E amih Dave i 109 o2 O zz w won B Smith Dave 3 028 Hale 2280 20120502 55 Seth Dave B9 100 15 00 isstruction per Calculate When all of the proposed goods and or services have been entered and any required fields in the Totalling section have been completed click CALCULATE calculates Tax HST and enters t
13. ed were available for you to receive but that you were unable to collect are added to the auto Insurer s Invoice o Minus Other Insurer 1 2 sum of all amounts received or payable to you from other Insurers This amount is taken from the Charged Services lines 2 and 3 Amounts paid to you or expected to be paid to you are subtracted from the amount billed to the auto Insurer Amounts that you previously stated were available for you to receive but that you were unable to collect are added to the auto Insurer s Invoice e Line 4 Tax o Taxis calculated at a default rate of 1396 to reflect HST If you wish to charge a rate other than 1396 you may edit this field e Lines 5 6 7 and 8 are used as the basis for interest charges that have accumulated This amount is not calculated into the Auto Insurer Total amount o While the interest amount is added to the total the amount owing from prior Invoices is not added to the total Enter Prior Balance the Auto Insurer Total from your last Invoice Subtract Payments Received since your last Invoice to calculate Overdue Amount Enter the interest owing as a result of the Overdue Amount Line 9 is Auto Insurer Total the sum of all amounts in this section Additional information In Tab 4 near the bottom of the HCAI page there is space that permits comments when there is a need to provide additional explanations clarifications to the Insurer Only 50
14. he amount into the Auto Insurer Total f you wish to manually enter a different tax amount for your invoiced goods services l Click and uncheck the button underneath the Totalling box ll Enter the new amount in the Tax if applicable field Click for the new Auto Insurer Total Figure 11 Totalling and Tax Amounts Totalling Sub total Minus MOH Minus Other insurer 1 2 Prior Balance 0 00 Payment Recerved from Auto insurer 0 00 Overdue Amount 0 00 Interest 0 00 insurer Total 149 20 ACA populates the propased and calculated tax columns with fhe HST rate 1396 You may overwrite the Proposed Tax amount if you are charging tax value that different from HST CALCULATE Recalculate proposed tax to reflect HST on selected taxable tems Ul 15 Prior Balance Overdue Amounts and Interest Charges O If the Facility has submitted an Invoice prior to the current Invoice but it has not been fully paid you may document the outstanding amount and associated interest on this Invoice Insert the Prior Balance which is the amount of the previous Invoice Insert the amount of payment already received on the previous Invoice Insert the overdue amount from the previous Invoice Insert the tax as calculated on the overdue amount Note The overdue amount will not be added to the Auto Insurer Total on this new Invoice Only the interest amount will be added to this Invoi
15. health Facility must use the space below to describe the attachment being sent How know my form has been submitted When your form is complete you may save it and a version will remain in the Invoices gt Draft sub tab for future use for this or another Applicant When you are ready to submit the form click on the button at the top or bottom of tabs 4 or 5 19 Return this form to Invoice Identifier Applicant Name Smith John _Prof Assoc Insurer Document Number 09031700002 Claim Number 1234 1 Main St Invoice Number 2 Policy Number 1234 Toronto Ontario OCF Type 21B Date of Accident 2008 05 05 M1M 1M1 Date Submitted 2009 03 17 Source Web OCF Effective Date 2006 03 01 You have submitted document number 080131 700002 Please note that the document is not considered complete until the attachments if any are indicated are received by the insurer CLOSE WINDOW Figure 15 is an example of what you will see if your form has been successfully submitted to the insurer Each OCF is assigned a unique Document Number by that can be used to track the form and distinguish it from others submitted for the same Applicant What if my form has not been successfully submitted Look for the error message in orange HCAI validates data entered in the application as you move through the first four tabs Errors will be flagged by an orange tab see Figure 16 or through error messages in yell
16. ior problem o Example Original injury is S73 Fractured femur The surgeon reports that the fracture is healed femoral fracture is resolved but ongoing treatment is required to manage pain and gait re education In this case the problems listed could be 79 6 Pain in limb and R26 Abnormalities of gait Should more space be required for additional injury or problem codes you may add extra lines Common codes Single physical injury refer to S codes Multiple injuries and bilateral injuries refer to T codes do not list duplicate codes for bilateral injuries Mental and behavioural disorders refer to F codes Symptoms signs abnormal clinical and lab findings not elsewhere classified refer to R codes Adding additional lines for injury sequelae codes To add lines for additional injuries simply click on the sign near the bottom of the box Figure 6 Add additional injury problem code line Injury and Sequelae Codes 1 ihe associnied ILL TI LA code tor puras amd ca for ICD 1 ser manual at www canoe 037 butto Description isolated proteinuria Tachycardia unspecified CONAAM CODES Refer to Appendix A which is the partial pick list of injury problem codes available at www hcaiinfo ca or contact your health professional association 12 Reimbursable goods and services Figure 7 Reimbursable Goods and Se
17. ithout an accident date If the patient has overlapping injuries from more than one accident use the date of the accident that is most relevant to the injuries being treated Date of birth of the Applicant Gender of the Applicant Invoice Identifier This information cannot be entered in Tab 1 Part 1 Applicant Information The Applicant patient or substitute decision maker should provide this information to the Facility Figure 3 Applicant Information Part 1 Applicant Information Please provide all information requested Values marked with an asterisk are mandatory fields required for submission Collection use and disclosure of this information is subject to all applicable privacy legislation Date of Birth 1956 06 12 N Gender 2 O Female Last Name Smith First John Middle Name Address 1 1123 Elm St Address 2 City Toronto Province State ON Ontario Postal ZIP Code M1M 1M1 Phone Part 2 Auto Insurer Information Applicant patient or substitute decision maker should provide the information last name of the Policy Holder is mandatory 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 direct Claim forms
18. lease enter the Document Number of the Treatment and Assessment Plan OCF 18 to which this invoice corresponds This is the eleven digit Document Number in the Plan Identifier section in the top right hand corner of the OCF 18 If you wish to indicate that this submission is exempt from providing the OCF 18 number answer No to the question above or type in exempt f your Facility uses an internal Invoice numbering system you may enter it in the Provider Invoice Number Field o This number will appear in the worklist and will help you locate an Invoice after you have submitted it o dtis not a mandatory field and may be left blank Click Yes for First Invoice if your Facility has not previously invoiced the Insurer for the associated Plan Click Yes for Last Invoice if this is the last Invoice to be submitted for the associated Plan Previously Approved Goods and Services Click Yes if the goods and services being invoiced are approved in the associated Plan and enter the Plan s Document Number o f you do not have the Document Number select Yes and type exempt into the Document Number field FSCO s HCAI Guideline explains when it is appropriate to request an exemption f your Invoice includes goods and services that are not included in an approved Plan select No This indicates you have selected an exemption from providing a Document Number Part 4 Payee
19. ow see Figure 16 Figure 16 Error notice orange tab Create OCF21B HEAO se 1 12 a s SIMA SEES P OS Sa SIE ee ges DELETE CANCEL PRINT SAVE SUBMIT Hm When you select a tab with an error an exclamation mark will appear next to the field with the error and a description of the error at the top of the section see Figure 17 Figure 17 Explanation of error Create 21 a a 2 User Manual PST DELETE f CANCEL PRINT SAVE Claim BM invoice Identifier Claim Number Test ancopsd invoice Humber 1 Policy Number Test anooptsdt OCF Date 2009054 Source Web OCF Effective Date 2007 04 02 Other insurer information Plesze provide details for other insurer coverage where applicable 20
20. r from the dropdown list and that name will populate all lines under Provider Ref Figure 10 Select line items for one Health Care Provider Reimbursable Goods and Services pp 1 1 Pian Use tee bubons on each tem io access supporti inais jelete m ine dem select ts check pox and rick Deisis aser manual al for cadie formals AMOUS Brs Descrbed EET 1 1 hg Date Code Provider Reference Quantity Measure Cost Tax Rendered 22080 EJ i i Hi 86 od mhr su 12 02 A 2 22 40 Exercme ines 2g 1270 532 5J E PI amp n resirueti n par Y 51 aD 4 Add more 5 APPLY CODES FROM PLAN mulli CODES CALCULATE COSTS FRH RATES HCAI enables HCFs to enter a default hourly rate for each Health Care Provider which will be used in calculating the cost per line of treatment Report the cost per service as described in the line o Example If the service was delivered for 0 5 HR the cost column should reflect the cost to deliver that service by the Health Care Provider listed for 0 5 HR o Note Do not insert the hourly rate in this column o Example 15 minutes of massage 0 25 HR by a massage therapist 25 of the RMT s hourly fee 0 25 x 53 66 13 41 This amount should be entered in th
21. rvices line Reimbursable Goods and Services Please enter the goods and Services rendered and the associated information requested To transfer codes from the plan click Apply Codes from Use the buttons on each line tem to access support took To delete a line tem select its check box and click Delete Refer to the user manual at www hcaiinfo ca Tor coding information Attribute codes are described in the manual If HST applies to a good or service check the Proposed Tax checkbox on that line item Date amp ervicezs Hu Code Attr Provider Reference Quantity Measure Cost Tax Date service rendered All dates on which Claimant attended for treatment should be listed Dates should be formatted yyyy mm dd and may be cut and pasted if several line items were delivered on the same date The calendar utility may also be used Figure 8 Figure 8 Date Services Rendered Date Services Rendered E 2012 05 03 Code Enter the intervention by typing it directly into the field under Code Or use the code search utility by clicking the blue button next to the Code field see Figure 9 Figure 9 Intervention code Code 1 09 Bj Stimulation ts Select either CCl Canadian Classification of Interventions or GAP o CCI are international standard codes for health interventions However some services were not well represented in the
22. ted Tab 3 Injury and Sequelae Codes Reimbursable Goods and Services Totalling Tab 4 Other Insurer Information Totallin Tab 5 Additional Comments and or Attachments TAB 1 Claim Identifier Persons who report injuries sustained in an automobile collision will be contacted by the Insurer to which they make the Claim for benefits The Insurer is required to provide the injured person Claimant with a Claim number date of loss etc The insurance Policy number can be obtained from the pink slip that is provided when the auto insurance Policy is issued Claim identifiers are used to identify the Claimant and match the document to a specific Adjuster s worklist When a form arrives at the insurance company the Insurer must match information contained in this section of the form Note Errors may delay the Insurer s ability to identify a Claimant and subsequently process the Claim Four key identifiers Four key identifiers will assist Insurers to quickly validate and adjudicate the Claim 1 Claim number and or Policy number Applicant must provide the Claim number if known the Policy number and the date of the accident o The Claim number and Policy number can be obtained from the insurance Adjuster o The Policy number is also available on the Motor Vehicle Liability Insurance Card pink Slip o The Claim number and Policy number may be the same The accident date forms will not be processed w
23. ting to coding of injuries interventions health care services and guidelines as they relate to your specific practice Examples of completed sections of the forms The examples and fees used throughout the manual are entirely fictitious They are designed to assist you in understanding how to use and complete the forms OCF 21B CREATE INVOICE FROM SCRATCH Introduction In HCAI your health care Facility HCF has two options for OCF 21B creation 1 Create an Invoice from scratch e This option is used when your Facility has not previously submitted an OCF 18 via HCAI o Example Services are delivered by a different HCF than the one that submitted the OCF 18 Create an Invoice from a Plan refer to OCF User Manual for OCF 21B Create Invoice from Previously Submitted Plan OCF 18 e This option can be used only once an OCF 18 has been submitted via HCAI Who completes this form to prepare it for submission to the Insurer OCF 21s that are being prepared on the Web application must be completed by the HCF that is seeking payment by the Insurer Applicant signature is not required What is the Insurer s role Fee After your HCF completes and submits the OCF 21 it will appear in the Invoices Work in Progress sub tab The Invoice will be in the Submitted state until an Insurer user views the form If the Facility has submitted a form in error the form can be withdrawn up until an Insurer user views the
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