OCF 21B From a Plan
Contents
1. DACE User Manual M i DELETE 1 CANCEL PRINT oe i Mg p sss Figure 14 Error notice orange tab 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 15 below Figure 15 Explanation of error I Create OCF21B 1 nh Sy FSS oS DELETE CANCEL PRINT SAVE SUBMIT COUUUUUEEM MM i Claim Identifier Invoice Identifier Applicant Mame sdfl asdfazdtfl ling test a Document Number Claim Mumber Test anoopsd disd Invoice Number 1 Policy Mumber Test sdf ontario OCF 21B Date of Accident 2009 04 01 Date 2008574 Source Web OCF Effective Date 2007 04 02 Other Insurer Information Please provide details for other insurer coverage where applicable I have made reasonable enquiries of the claimant and have determined that 122. je Code Attr Provider Reference Quantity Measure Cost Tax cross zscos Dianna Lueck tg zooses 22 JW inna szzem Dinna Lueck jew jew m B Lj Uo Ff m jew DELETE APPLY PROVIDERS PE EEA TEE GJ Use these buttons with the checkboxes on the left APPLY CODES FROM PLAN CONFIRM CODES CALCULATE COSTS FROM RATES 5 is explained in Chapter 5 of the Web User Manual 6 If none of your goods and services require tax then once you are satisfied the Invoice represents the goods and services for which you wish to invoice click will complete the math for you Calculating Tax 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 aasccaled niormation requesied transfer codes from the pian Apply Codes irom Pian Use tee bubons on each ine tem access support To delete ine dem select its check and Deeja Refer to the user manual al wy for coding information Afiribute comes are described n manual 1 app es in amp good or amp ervice check he Checkbox thal
3. 15 02 Exercise spinal vertebrae E March 2009 Y CostiDay on Plan 25 00 Court a 7 ooo 00r 8 9 10 11 12 13 14 CODCIOU 15 16 17 18 19 20 21 24 25 26 27 28 29 30 31 1 2 3 4 5 8 8 10 11 CANCEL APPLY CODES FROM PLAN 4 All of the goods and services along with the Provider reference quantity measure and cost will populate the Invoice Figure 8 Note It is possible to edit the lines of goods and services in case the treatment delivered or the Provider changed during the course of the treatment Plan It is also possible to add goods or services that did not appear on the Plan Figure 8 Invoice will populate itself with services proposed in Plan Reimbursable Goods and Services Please enter the goods and zerwicezs rendered and the associated information requested To transfer codes from the plan click Apply Codes from Plan 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 ww w hcalinfo ca for 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
4. Health Claims for Auto Insurance OCF 21B CREATE INVOICE FROM PREVIOUSLY SUBMITTED OCF 18 PLAN MANUAL FOR WEB USERS Comparable to OCF 21A July 2012 Table of Contents WHEN DO TUSE AN OCF 21B acs cee ses a EE EEEa 4 WHAT IS INCLUDED IN THIS MANUAL 1 3 3 1 1 3 4 WHERE CAN GET MORE tentent 4 EXAMPLES OF COMPLETED SECTIONS OF THE FORMS eese nennen nennen eret 4 OCF 21B CREATE INVOICE FROM PREVIOUSLY SUBMITTED PLAN 18 REPLACES OCF 21A 5 DUCH caseus Eun gen Ste M MN M MEL IM a ented ME C EI E IEEE 5 WHO COMPLETES THIS FORM TO PREPARE IT FOR SUBMISSION TO THE 0 5 WHAT 1S THE INSURER S ROLE C xw boe ed 5 6 CREATE INVOICE FROM PLAN SUBMITTED VIA 6 seine 1 2 CLAIM E 10 PEL c ER mM 2 PART APPLICANT INFORMATION 2 PART 2 AUTO INSURER 2 TAD
5. Date Code Attr Prowmder Reference Quantity Measure Cost Eg amih Dave 160 B 69 won 3 Smith Dave ff 028 2250 Exercme inas j 20120602 Tac 59 Smith Dave 100 25 00 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 the amount into the Auto Insurer Total If you wish to manually enter a different tax amount for your invoiced goods services o Click and uncheck the button underneath the Totalling box o Enter the new amount in the Tax if applicable field Click for the new Auto Insurer Total Figure 10 Totalling and Tax Amounts Sub total Minus MOH Minus Other insurer 1 2 Tax if applicable Prior Balance 0 00 Payment from Auto insurer 0 00 Overdue Amount 00 Interest 0 00 Auto insurer Total 149 20 HCA populates the proposed and calculated tax columns with fhe HST rate 1396 You may overwrie the Proposed Tax amount if you are charging a tax value amp different from H5ST CALCULATE Recalculate proposed tax to reflect HST selected taxable tems Prior Balance Overdue Amounts Interest Charges the Facility has submitted an
6. 3 PARTS eziE IINE 3 4 PAYEE INFORMATION ccccceccececcececcececcececaccecececeececuececueaucsececaeusucesecseuececauauceuaeceuauceuaeeas 3 pfo 4 INJURY AND SEQUELAE 1 4 REIMBURSABLE GOODS AND SERVICES 00 000 ranana anara CALARE sese sage sage saga esa e sages 6 9 OTHER INSURER INFORMATION 20 0000118000 sese sss sese sase sage se sagesse eg sage rss re siia 9 CHARGED SERVICES SERVICES CHARGED TO OTHER 2 2 22 2100 nnnnn innen nnns nnn Bor HET c ON IDEO MERO Ma E ORI DERI TON SA IE RUM S UR EN ME HOW DO KNOW IF OCF HAS BEEN SUBMITTED WHAT IF MY FORM HAS NOT BEEN SUCCESSFULLY SUBMITTED When Do Use an 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 provid
7. injury first i e the patient s most significant condition that is directly related to the automobile accident and that requires health care services Example If psychological services are required after a brain injury the first code listed should reflect the reason that psychological services are being proposed F07 2 Postconcussional Syndrome S06 Concussion In a case where multiple injuries may be classified as the most significant list the injury requiring the most services first a 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 i e a resolved problem can be considered a prior problem o Example Original injury is S73 Fractured femur 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 M79 6 Pain in limb and H26 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 disorder
8. on a Plan but the Insurer may request an explanation e 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 stated 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 df you wish to charge Tax you must copy the amount calculated and shown in the right hand column and enter it into this field under the Proposed column 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 prio
9. 8 Document Number 120612300002 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 HCAI 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 o Yes is chosen by default to indicate this Invoice is for goods and services approved in an OCF 18 The corresponding Plan s Document Number is auto populated Part 4 Payee Information When the HCF is registered the Facility will have chosen Yes No to the question Lock Payables o If the HCF selected Yes the field next to Make Cheque Payable to will be pre populated o If the HCF selected No the field next to Make Cheque Payable to must be completed Figure 4 Payee Information Part 4 Payee Information Mame Sara_Code AISI Facility Humber 35444 Make Cheque Payable To Payment 34 toronto street toronto ontario Payee First Name Sara Payee Name Miller Payee Humber Address 1 33 Toronto st weet Address 2 update facility City Toronto Province Ontario Postal Code u7i3e4 Phon
10. 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 Invoice The previous Invoice is still effective and amounts from prior Invoices should not be added to new Invoices TAB 4 Other Insurer Information Figure 11 Other Insurer Information Other Insurer Information Please provide details for other insurer coverage where applicable hawe made reasonable enquiries of the claimant and have determined that Q There is ne other insurance coverage e Wes There is other insurance coverage that is potentially available to cower partially cover these goods and services MOH there Ministry of Health and Long Term Care coverage for goods and Services included in this form O Yes Not Applicable Other Insurer 1 Pleaze provide details Tor other insurer coverage where applicable Other Insurer Name SunLInf Plan Or Policy Number Of Last Name of Plan Member FirstName of Plan Member Other Insurers Identi
11. as generated because there was a question about the degree of Health Care Provider dependency The ICD 10 CA code would be Z74 problems related to Health Care Provider dependency o Example 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 ESAL ATTI 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 ICD 10 CA codes are not profession specific o 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 In other words it should reflect the primary reason you are proposing services with the most significant
12. djudicated 1 of 4 The folowing tems were recently Vier 50 Mama 32234Next gt 20516 Smith Aperwed 201 Go to the Plans gt Adjuster Response sub tab see 1 Locate the adjudicated Plan and click on the blue icon to the left of the Plan that has been approved see Figure 1 SS ay adjudicated Plan will open Click see Figure 2 and the Plan will be converted into an OCF 21B in HCAI the OCF 21A does not exist of the fields will be populated from the approved OCF 18 Figure 2 Create Invoice from Plan Review 18 H C RI FEED T ab ER T Ej m sp wat 3 i x 2 3 qure ets CREATE PLAN CREATE INVOICE WiTHORAW LANCE PRINT OCF 21B TABS The OCF 21B appears organized under five tabs as seen in figure 2 Tab 1 Claim Identifier Invoice Identifier Part 1 Applicant Patient Information pre populated Part 2 Auto Insurer Information pre populated Tab 2 Part 3 Invoice Details Part 4 Payee Information pre populated Tab 3 Injury and Sequelae Codes Reimbursable Goods and Services Totallin Tab 4 Other Insurer Information Totallin Tab 5 Additional Comments and or Attachments TAB 1 Claim Identifier No edits are possible This data will be populated from the data entered on the OCF 18 Inv
13. e 416 9996665 Fax E mail smiler ibc 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 faleehond or other dishonest act to defraud or attempt 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 and preventing fraud Note Authorized signatures obtained during registration TAB 3 Injury and Sequelae Information Invoicing for goods and services proposed on an OCF 18 The injuries identified in the OCF 18 will populate this field lf the injury or problem has changed since the Plan was approved it is possible to edit the codes add additional codes Invoicing for assessment services e invoicing for assessment services enter the injury problem code s most appropriate for the Claimant based on the assessment findings e f 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 w
14. es detailed instructions for the completion of OCF 21B using the Web application Where can get more information This manual will be updated from time to time The latest updates to the manual can be downloaded from www hcaiinfo ca Contact your Health Professional Association for any questions relating 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 this manual are entirely fictitious They are designed to assist you in understanding how to use and complete the forms OCF 21B CREATE INVOICE FROM PREVIOUSLY SUBMITTED PLAN OCF 18 Replaces OCF 21A Introduction In HCAI your Health Care Facility HCF has two options for OCF 21B creation 1 Create an Invoice from a Plan e This option can be used only once an OCF 18 has been submitted HCAI o Example The OCF 18 is submitted via HCAI to the Insurer and the Plan is approved The user can open the submitted OCF 18 located in the Plans gt Adjuster Response sub tab and o OCF 21B will be generated o OCF 21B will be pre populated with Applicant demographic and Insurer information Injury codes for OCF 18 Goods and services can be populated automatically requiring only the dates of treatment to be entered 2 Create an Invoice from scratch see OCF User Manual f
15. fier O Other Insurer 2 Please provide details Tor other insurer coverage where applicable Other Insurer Name Plan Or Policy Humber f LastName of Plan Member si First Name of Flan Member Other Insurers Identifier O Select Yes or No to establish whether there is other insurance coverage m 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 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 a 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 sub total automatically Totalling There are 9 lines in this section It is possible to bill for amounts greater or less than those proposed
16. nts must be faxed mailed to the Adjuster indicate that an attachment is being sent to the Adjuster tick the box beside Attachments being sent if any If this box is ticked the HCF must use the space below to describe the attachment being sent How do know if my OCF has been submitted When your form is complete you may save it and a version will remain in the Invoices Draft sub tab for future use When you are ready to submit the form click the button at the top or bottom of Tabs 4 or 5 Figure 13 Successful form submission notice Create OCF21B Return this form ta rou have submitted document number 09031700002 Feart note that ihe document is not considered complebe until tee attachments If any ane indicated are recetead the inure Figure 13 above is an example of what you will see if your form has been successfully submitted to the Insurer system assigns each OCF a unique Document Number that you can use to track the form and distinguish it from others submitted for the same Applicant 1 What if my form has not been successfully submitted for the error message in orange o validates data entered in the application as you move through the first four tabs o Errors will be flagged by an orange tab see Figure 14 or through error messages in yellow see Figure 15 Create HCA x kx 2 PEE NE IU TUS D STEP NO
17. oice Identifier This is blank The Invoice number is populated in Tab 2 Part 1 Applicant Information No edits are possible This data will be populated from the data entered on the OCF 18 Part 2 Auto Insurer Information No edits are possible This data will be populated from the data entered on the OCF 18 Documenting Errors or Changes to information in Tab 1 If there are changes or corrections required to the information in Tab 1 notify the Insurer who can change the data in the HCAI system TAB 2 Part 3 Invoice Details Figure 3 Invoice Details Part 3 Invoice Details Te aid the decision making sroceas please the plan for tis claimant that i associated wih Iis invoice and whether or nat fhe frst or 851 invoice under this plan Provider invoice Number First Mn vem Last voice Previously Approved Goods and Services ror previmusly approved goods and services pease commete the folowing ls this invoice for goods and services approved on an OCF 18 in HCAS Messe enter tne HL AI Document Number af the frestment and Assessment Plan 183 fp which inwoice Corresponds This amp the Even digi Document Number in the Plan identifier section Ie tnp right hand corner of the DCF 1B If you with 1o indicate that his submission m Di exempl from providing fhe DCF 18 number answer Mo ta the questen above or type in exempl OCF 1
18. or OCF 21B Create Invoice from Scratch This option is used 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 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 o the Facility has submitted a form in error the form can be withdrawn up until an Insurer user views the form After the Adjuster matches the form to the Claimant the form can be adjudicated At that point the form will continue to appear in the Invoices gt 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 gt Adjuster Response tab where it can be viewed online and or printed Fee There is no fee payable for completing the standard Invoice Create Invoice from Plan Submitted via HCAI To create an OCF 21B from an OCF 18 that has been submitted and or approved do the following Figure I Plans Adjuster Response sub tab Sara Code 8 Li L r User Manual OGOUT lim All Forms 2 sof ocre A
19. r Invoices is not added to the total o Enter Prior Balance the Auto Insurer Total from your last Invoice o Subtract Payments Received since your last Invoice to calculate Overdue Amount o Enter the interest owing as a result of the Overdue Amount The interest amount will be added to the Auto Insurer Total e Line 9 is the 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 if there is a need to provide additional explanations clarifications to the Insurer Only 500 characters are allowed here If more space is needed use 5 Figure 11 Additional Information 5 Additional Information Make cheque payable Acme Rehab Other Information 10 TAB 5 Additional Comments amp Attachments Figure 12 Additional Comments and attachments Additional Comments Messe note that the do i Lm not conakdergd compete unii the attachments if amy are Medicated are recgre exdg Ey ihe insure i mendatory i 6 dacurmentare 5 thal are hem Family physician repsrt enelosed enables HCFs to o Offer more information to Adjusters by using the space provided Tab 5 o Advise Adjusters that additional documentation attachments is being sent which the insurer requires to adjudicate the form Attachments cannot be sent electronically via HCAI Attachme
20. ribute codes are described in the manual H HST applies ip a good or service chock the Tax checkbox on that ine Date Services Code Attr Provider Reference Quantity Measure Cost Tax a F APPLY PROVIDERS Use tese buttons wih the checkboxes on the APPLY CODES FROM PLAN ru yii CODES CALCULATE COSTS FROM RATES 2 screen will open that has a calendar to the right of each line of goods and services that were listed on the Plan e Use the calendar function to select each date on which the specified service was delivered to the patient 3 When all lines have been completed click Figure 7 Select dates on which service was delivered Seledt each previously approved good and service by using the calendar to identify the date s of delivery When all services and delivery dates have been identified click Apply Codes from Plan To return to the invoice without applying the date s of delivery click Cancel CANCEL APPLY CODES FROM PLAN HXXMR Med Rehab Cost Day on Plan 100 00 Total Count Fa 2p sp ap C m e e ro v 12 v5 Provider Reference Riis Viivi Dates of Service 25 08 Test spinal vertebrae E March 2009 Y Cost Day on Plan 22 75 Sun Tue Wed Thu Fri Total Count 6 Quantity 0 25 SD Provider Reference Riis Viivi Dates of Service 2 st 1 2 3 4
21. s 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 To add lines for additional injuries simply click on the sign near the bottom of Part 7 Figure 5 Add additional injury problem code line Injury and Sequelae Codes Provide the associated ICD 10 CA code for injuries an er ip the user manual at for ICD T0 CA coding info search using But Description isolated zB Tachycardia unspecified CONAAM CODE g 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 Reimbursable goods and services When an Invoice has been created from a Plan it is possible to populate this section with the goods and services listed on the Plan that was used to create the Invoice To do this follow these instructions 1 Click APPLY CODES FROM PLAN Figure 6 Apply codes from Reimbursable Goods and Services Please enter tha goods and services rendered and the associated information requested To transfer codes from the plan cick Apply Codes from Use the buttons on each ine to access support took delete line dem select Rs check box and cick Delete Refer to he user manual at www heganfo cg for coding nformabon Att
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