Chapter 7: Using Decision Support with Plans
Contents
1. Claim 1999 Claimant Details Fill in the fields to add edit a cdaimant for Claim 1999 MOTE All fields with an asterisk ane required Date of Birth 1941 12 31 it Gender Male C Female Claimant ID Ferg Last Name Ferguson First Name Alex Middle Name Address 1986 Govan Park City Toronto Province State ON Ontario PostalZIP Code M4G 261 Adjuster Gudjonnsen Edith A Cisse Djibril Sudjonnson Edith Henry Tamara Keane Robin Min Samuel 10 Insurer Manual Chapter 7 Plealift Claim for Aul Iiniurancte Working With the OCF 18 Treatment Plan Confirmation Form In the OCF 18 the information submitted by the Facility that is displayed in Tabs 2 4 is read only and can be reviewed by clicking on the respective Tabs representing each screen After reviewing the supporting information in the form approval decisions are made in the Tab 5 screen You may approve or decline each of the line items proposed by the Facility If you are declining any of the line items in the plan you must apply a reason code To assist you in making your decision the Associated Documents list for the Claimant displays in the upper part of the Tab 5 screen It is the same list and functions in the same manner as that on the Summary page Part 12 Proposed Goods and Services This section contains the line item goods and services proposed by the Facility Part 12 Proposed2. 00 KM Mileage Frovider B ATT Saikali Claudia TH Travel Time Prow E Apply multiple reason codes SET CHARGED COSTS TO APPROVED COSTS SET REASOW FOR DECLINING Totalling Preapproved Sub total Other Goods and Services Auto Insurer Total CALCULATE OR if you wish to approve the other Goods or Services as submitted without any modifications SET CHARGED COSTS TO APPROVED COSTS Inthe Apply multiple reason codes section click the button No reason Necessary The Cost boxes are updated automatically to display the same values selections as proposed by the Facility To deny proposed goods and services To deny goods and services proposed by the Facility you must provide a reason code s to support the deny decision If you are only denying some of the proposed goods or services and or partially approving proposed goods or services Inthe Proposed Goods and Services table set the amounts proposed by the Facility in the Estimated Fee to 0 or less than the proposed amount by entering the amount directly into the corresponding boxes below the proposed amount Click the ellipsis button l next to each good or service to search for the reason code and to add it to the Adjuster Response column For more information please see Specifying Reason Codes in Chapter 5 22 Insurer Manual Chapter 7 Plealift Claim for Aul Iiniurancte OR if you wish to deny all propos
3. Goods or Services Requiring Insurer Approval Estimate Day Projected GS Total Total Proposed Adjuster Refi Code Attr Provider Reference Quantity Measure Cost Count Cost Tax cee 1 3 AN 12 Wirebound Maria 1 00 HR 1500 00 10 15 000 00 3 03 15 Fluoroscopy 0 00 lo 0 00 A Sg brain d Pending Agreement By All Parties Estimated duration of this Plan amp weeks How many treatment visits have you already provided The list includes GS Ref The record number of a given good or service Code This column contains the CCI or GAP code associated with the good or service as well as the description Attribute The good or service attribute if applicable Provider Reference This column contains the name of the Provider who will be providing the good or service Click on the name link to open a separate window and view the Provider details or running your mouse over the name displays the Provider profession Quantity Measure This column contains the quantity of the good or service to be delivered per visit and the unit of measure for this quantity Cost This column contains the cost per good or service unit as proposed by the Facility It also has an associated active box for the User to confirm or modify the amount submitted by the Facility Total Count This column contains the total number of goods or services units to be delivered as proposed by the Facility It also has an associated active box for the U
4. SAVE 2013 Health Claims for Auto Insurance Processing Privacy Policy 26 Insurer Manual Chapter 7 NEd0 Health Claims for Auic Insurance There is only one place that can be edited Tab 2 Interest payable can be added HCAR a Hoa T 7 User Manual i Create OCF9 CANCEL j PRINT SAVE Part 4 Medical and Rehabilitation and Other Benefits Claimed Payable Dayable 51 500 00 1 500 00 X Ray of the Cervical Spine 200 00 5200 00 C stimulation muscles of the back 530 00 swo Part 5 Insurance Company Information Name of Insurance Company Representative Rafa Benitez Name of Ingurance Company KOH Global Re Telephone Number 905 331 3239 Signature of Insurance Company Representative F _ E CANCEL l PRINT SAVE 2011 Health Claims for Auto Insurance Processing Privacy Policy Tab 4 Additional Comments field Select Tab 4 to add additional comments Create OCF9 HCA step 1 2 a r k A a x CANCEL PRINT SAVE SUBMIT Additional Comments F Attachments being sent Append a brief message to the EOB explaining the approval decision Maximum 20 000 characters gt Click SAVE This saves any changes made to the Additional Comments field and saves the document as a draft it will not be viewable to the Facility Click SUBMIT CONFIRM then click l and the document will be available for the Facility
5. and roles you can reassign the Claimant to a different Adjuster within your insurance company Part 2 Auto Insurer Information Selected Insurer Information Company Name HCA Test Insurer Branch Name HCA Insurer Main Branch Branch Address 2 King St Auto Insurer Information On Form Company Name HCA Test Insurer Branch Name HCAl Insurer Main Branch Branch Address 2 King St City Toronto City Toronto Province Ontario Province Ontario Postal Code M1M 1M1 Postal Code M1M 1M1 Policy Holder Details Policy Holder Last Name Policy Holder First Name Policy Holder Details Policy Holder Last Name Policy Holder First Name Mackinnon Mackinnon Adjuster Details Last Name First Name Phone Fax Adjuster Details REASSIGN ADJUSTER Last Name Adjuster First Name Test Phone Fax To Assign or Reassign an Adjuster Click the E button of the Auto Insurer Information section A confirmation message appears If you have saved all your work on the form click lt OK gt to proceed to the Claimant Details Screen where the Adjuster assignment can be changed Click on the dropdown box titled Adjuster and select the Adjuster to whom the Claimant is to be assigned or reassigned and press SAVE KOH Global Re Sal HCA g Sy 7 User Manual INVOICES SEARCH 5 MANAGE PLANS CLAIMS Claims gt Claimant Search gt Claimant Details for Ferguson Alex gt
6. proposed by the Facility and the Approved column shows the amount approved by the Adjuster The totals are automatically updated each time the BASS button is clicked Approving or denying all of the line items by using the Apply multiple reason codes functionality will automatically update the calculated totals Credits for expected payment through the Ministry of Health or other Insurers can be noted here to modify the approved amount They must be entered with a negative minus sign Totaling Adjuster Proposed Approved Calculated Response Total Count 3 0 Sub total 434 00 0 00 Minus MOH 0 00 Fj Minus Other Insurer in 1 2 sees EJ Tax if applicable 35 00 B Auto Insurer Total 473 00 0 00 CALCULATE 14 Insurer Manual Chapter 7 068 Health Claims for Auic Insurance Part 13 Signature of Insurer This section is where the User validates the approved or declined line items on the plan by recording an approval decision at the plan level ignature of Insurer Please confirm whether you waive the requirement of the applicant s signature Use the decision buttons to submit your decision If applicable provide a message to the provider Insurers are advised not to waive claimant signature unless they are in possession of a signed OCF 1 Adjuster s First Name Alberto Adjuster s Last Name Degas Is the applicant s or substitute decision maker s signature waived by the insur
7. to Applicant Name Suarez Luis Claim Number A45 Policy Number B83897654 Date of Accident 2072 05 01 Plan Details Document Number 13060300002 Owner BGR se Status Review Required Additional Attachment Details OCF Type Date Submitted Source OCF Effective Date Archival Status 18 2013 06 03 Web 2012 11 04 Not Archived Please specify the date that the attachments have been recened The date that the attachments are recered once set cannot be edited attachments Receves oat Message Log Here is a list of messaging associated with this document There are no messages Activity Log Activity Log for Document 13060300002 2010603 12 15 HCA Application matched claimant and applicant on a document 2013 06 03 12 15 Robertsonski Kian submitted a plan Associated Documents Results Associated Documents 1 of 1 Showing associated documents which are active To show archived documents click Show Archived Documents 120861500001 12091200008 13052800003 13052800011 CANCEL OCF1 OCF21B OcCF1 OCF1 OCF1 Facility Health 4 Life Health 4 Life Health 4 Life Health 4 Life Health 4 Life Status Approved Approved Approved Partially Approved Approved Date Sent 2012 0810 2012 0815 2012 0912 20130528 20130528 SHOW ARCHIVED DOCUMENTS Proposed Amou L nt S tl 2 375 00 1 200 00 2 375 00 5 680 25 5 683 25 r r PRI
8. to view Click CLOSE io go back to the Plan on 27 Insurer Manual Chapter 7 E80 Health Claims for Auic Insurance PRINT To print the Explanation of Benefits click I It is printed as a PDF document To view an EOB Click the Review Form button 2 next to the plan you wish to open in the Adjuster Response work list under the Plans tab that has a green check icon wl Click at the top or bottom of any of the steps A Note The Facility is able to see the same information that is in the EOB in an area called View OCF9 on the Facility s associated Provider s side of HCAI Review OCF18 HCAR summary 1 2g 2 1 2 Ea 7 User Manual CANCEL VIEW OCF9 Claim Identifier Retum this fonm to Plan Identifier Applicant Name Suarez Luis KOH Global Re Document Number 12081000005 Claim Number 445 2 Speyside Way Policy Number BeoTesd Acton Ontario Date of Accident 2072 05 01 L2P 6p2 OCF Type 18 Date Submitted 2012 08 10 Source Web OCF Effective Date 2010 09 04 Archival Status Not Archived Plan Details Document Number 12081000005 Owner Status Approved 28 Insurer Manual Chapter 7 068 Health Claims for Auic Insurance Withdraw Response from an Adjudicated Plan To withdraw a Plan which you the Insurer have already responded Go to the Plans tab of the Insurer home page select the Adjuster Response tab and navigate to the desired P
9. 01 Archival Status Not Archived Plan Details Document Number 13011700003 Owner TAKE OWNERSHIP p Status Review Required Message Log Here is a list of messaging associated with this document There are no messages Any EOB associated with the withdrawn Plan is also withdrawn After one year has passed from its adjudication date the Plan is automatically placed into a read only state Once in read only the Plan can still be printed but no modifications of the Plan in HCAI can occur 29 Insurer Manual Chapter 7
10. 05 06 09 L2P 6p2 Date Submitted 2005 07 09 Source Web OCF Effective Date 2007 05 01 Part 1 Applicant Information Note This Document is owned by Claimant Details Insurer Claimant Information Date of Birth 1972 08 30 Claimant Information on Form Date of Birth Gender Parae Gender Male Last Name Diaz First Name Carmen Middle Name Address 1 Address 2 City Toronto City Toronto Last Name Diaz First Name Carmen Middle Name Address 1 5 San Diego Place Address 2 A UNLINK CLAIMANT DATA 5 San Diego Pl Province State ON Ontario PostalZIP Code M2T 2T3 Phone Province State ON Ontario PostalZIP Code M2T 2T3 Phone The left part of this section contains the Claimant Information as submitted by the Facility In the right half there is a section for the Insurer Claimant Information HCAI links the submitted document to the Claimant automatically if there is a perfect match between the Applicant information and the Claimant information A perfect match occurs when all of the following pieces of information are exactly the same for both the Applicant and the Claimant policy number and or claim number date of accident gender date of birth 9 Insurer Manual Chapter 7 O60 Health Claims for Avia Insurance PART 2 Auto Insurer Information In this section you can see the Insurer and Adjuster details as specified by the Facility If you have sufficient access rights
11. NT SAVE 2013 Health Claims for Auto Insurance Processing Privacy Policy Insurer Manual Chapter 7 068 Health Claims for Auic Insurance Message Log Message Log Here is a list of messaging associated with this document Date amp Time Description Actor 2005 09 03 Coverage for experimental treatments possible Please contact via phone Benitez Rafa Message to Provider SEND MESSAGE The Message Log section is where communication between the Insurer and Facility is viewed When you open a plan for the first time the Message Log section is blank If you initiate the Need to Discuss feature when adjudicating an OCF this section contains an historic list of messages and a blank field you can use to continue messaging with the Facility The list of messages includes Date and Time Description containing the body of the message and Actor the name of the person who wrote the message The list is sorted by date with the most recent message at the top In the Message to Provider field you can type short messages to send to the submitting Health Care Facility Clicking attaches the message to the plan The Facility can view this message from a similar area and respond as required Message Logs are not archived with the plan If you wish to retain a record of messages you must print them out or cut and paste them into another document for storage in a paper file Activity Log Activity Log Activ
12. T SAVE Explanation of Benefits Payable by Insurance Company OCF 9 Use this form for accidents that occur on or after November 1 1996 Document Number of Linked Plan 13052800001 Claim Number 738934_99 37 Policy Number RE 338354 Date of Accident 2010 05 05 Revised 2013 06 03 OCF Effective Date 2006 03 01 Submitted to Facility No Archival Status Not Archived Part 1 Applicant information Last Name Cruz First Name and Initial Middle Name Penelop Address 851 Madridista Blvd City Toronto Date of Birth 1974 04 28 Part 2 Income Replacement Non Earner or Caregiver Benefits Payable We have reviewed your application for income replacement benefits and have determined you are F A Eligible Details of how we calculated your income replacement benefit including adjustments for income or payments from other sources Calculation Gross Weekly Income Netincome 80 of Net Weekly Income Minus Post_Accident Net Weekly Income Payments from Other Sources Income Replacement Benefits Payable Non Earner or Caregiver Benefit Payable F B Not Eligible Stoppage of Benefit Part 3 Catastrophic Impairment Determination We have reviewed your application for determination of catastrophic impairment and have determined F You have sustained a catastrophic impairment as a result of the accident F You have not sustained a catastrophic impairment as a result of the accident for the following reasons CANCEL PRINT
13. WGO Health Claims for Auto Insurance INSURER USER MANUAL Chapter 7 Using Decision Support Plans HICIA Health Claims for Auto Insurance Chapter 7 Using Decision Support Plans OVERVIEW The HCAI Plan Review is designed to assist in the process of reviewing and applying approval decisions to the OCF 18 and OCF 23 This section describes how to work with plans OCF 18 and OCF 23 in HCAI Regardless of which plan you are reviewing the HCAI Plan Review includes the Summary tab a quick overview of the plan and associated documents and the plan itself organized in a manner similar to the paper OCFs Depending on the roles you have been assigned in the system you can link and unlink Claimants reassign Adjusters search for and apply reason codes exchange messages with a Facility make approval decisions on plans and view the Explanation of Benefits EOB Some of the HCAI functions used in decision support are explained more fully in Chapter 5 Common Functionality SPECIFYING FREASON GODE Sigecccsnte vec cetncassemintecdewtetdctentouec cetaiessntasietienteddeeeniawetdonianasteieienetdcwiatestenienetiecatettons 2 NOTIFICATIONS AND ERROR MESSAGEG scsceeecceeeeceeecnececeuceceneeneeeeuueecaueeeeneenseeeneeeeaueesaneenueeueeesaeeeneneenaess 2 PRINTNGA DOCUMENT wcsccctaactacachuencranagtainnaretecaeatatetasataisdtantadetaamontcanatotermcatatementatcdineimeacstaaace dar iia nRa 2 OCF PLAN REVIEW cc tacge cae oettrpa
14. arch for a reason code see Chapter 5 Common Functionality Notifications and Error Messages If any error is detected when you are validating a completed step a notification appears at the top of the screen in red font with an orange background A more detailed error description is provided in the header of the section where the error occurs and a red exclamation mark appears next to the field that contains the error Printing a Document You can print plans or invoices by using the button available at the top and bottom of the screen as you navigate through the document For instructions on how to print a plan go to Chapter 5 Common Functionality OCF Plan Review There are two parts to OCF Plan Review in HCAI 1 the Review and 2 the Adjuster Response The first includes a read only review of all the plan information completed and submitted by the Health Care Facility The online forms have the same structure as the respective paper OCFs This section does not describe how to review the forms its focus is to guide you through the online procedure of applying submitting decisions and to explain how to use the HCAI functionalities The description of the Summary tab and Tab 1 is common to the OCF Plan Review for each of the forms The last step where approval takes place is described separately for each A Note The last page of each form has a section for additional comments from the Facility and or associated Provider
15. ate Day Projected GS Code Attr Provider Reference Quantity Measure Cost Total Total Proposed Adjuster Ref Count Response 12 22 02 1 pl 1 00 HR 25 00 1 Siy pi pi Assessment exam 0 00 0 0 00 E Estimated duration of this Plan 1 weeks How many visits have you already provided 0 visits Has the applicant or substitute decision maker confirmed consent by initialing the proposed goods and services No Apply multiple reason codes SET CHARGED COSTS TO APPROVED COSTS SET REASON FOR DECLINING Adjuster Proposed Approved Calculated Response Total Count 1 0 Sub total 25 00 0 00 Minus MOH 0 00 0 00 Minus Other Insurer 1 0 00 0 00 2 i i Tax if applicable 3 25 0 00 Auto Insurer Total CALCULATE The screen refreshes with the Cost Total Count and Proposed Tax active box are updated automatically to display the same values selections as proposed by the Facility To deny proposed goods and services To deny goods and services proposed by the Facility you must provide a reason code to support the deny decision If you are only denying some of the proposed goods or services Inthe Proposed Goods and Services table set the amounts proposed by the Facility in the Cost Total Count boxes to 0 by entering the amount directly into the associated active boxes below the proposed amount and uncheck the Proposed Tax box if necessary Click the ellipsis bu
16. ce from same provider Review OCF18 Select the Series that is appropriate for your decision To begin your search click Search To narrow down the search results you can supply a Category and or Reason prior to clicking the Search button Series Unable to authorize administrative Y Category Administrative v Reason Duplicate form good or service from same provider Y SEARCH CANCEL 2015 Health Claims for Auto Insurance Processing Privacy 18 Insurer Manual Chapter 7 OGO Health Claims for Auic Insurance Scenario 2 Facility Provider wants to take back a form that has been submitted to the Insurer and adjudicated When a Facility and or associated Provider wants an Adjuster to withdraw an adjudicated form either because of duplicate processing or because the treatment is no longer required the adjuster must withdraw the response first and then decline the form To withdraw a response Go to the Plans tab of the Insurer home page select the Adjuster Response tab and navigate to the desired Plan Click the Review Form button B next to it The Plan opens at the Summary screen Review OCF18 HCR E a N ss NEXT l User Manual CANCEL CREATE OCF Claim Identifier f Plan Identifier Applicant Name Zidane Zinedine Document Number 13077700008 Claim Number 189 aby _099 ea j OCF Type 18 Policy Number 8765 cton i Date Submitted 2013 0117 Date of Ac
17. cident 2072 06 14 P 6p Source Web OCF Effectwe Date 2012 11 04 Archival Status Not Archived Plan Details Document Number 13011700008 Owner Status Approwed Message Log Here is a list of messaging associated with this document i Click the WITHDRAW RESPONS button beneath the Document Number in the Plan Details section A message appears asking you to confirm withdrawal Click lt OK gt in response to this message This returns you to the Plan The status of the Plan in the Plan Details section on the Summary page is changed to Review Required and the Plan is moved to the Plans Work In Progress work list Once the form has been withdrawn the insurer can decline the form using the steps outlined in Scenario 1 above 19 Insurer Manual Chapter 7 Plealift Claim for Aul Iiniurancte Adjudicating the OCF 23 Treatment Confirmation Form The Summary Tab and Tab 1 are common to all of the plans in HCAI The information contained within Tab 2 of the OCF 23 is read only information submitted by the Facility In the OCF 23 approval decisions are made in the Tab 3 screen Here you may confirm whether a valid policy of insurance was in place at the time of the accident and then hit submit Part 9 Guideline Services This section contains the line item list of goods and services as proposed by the Facility The section contains PAF WAD1 and WAD2 Minor Injury Guideline MIG and Supplementary Go
18. cte ecto A a aa e iaa aiai 2 OOF TO ROVIO W arei E E esate E E E E E aa 2 JCS PROVON ee E E E E E E deers 2 LAUNCHING OCF PLAN REVIEW cccccecccececececeeeceecececeueceueceueeeueeeseeuceeueeueeueeeneeeueeeneeeneeeeeeeeeeeeneeeneeaneeanesees 3 SUMMARY TAP orei E EAE aon acainachin pred a Aes enact ene anenaeee peace E ance EET 4 FF FNS e eee cn tetera eae seyret ceria ond cts une E Seance dea eae nda E A E A Neate taeda se E E 5 Additional Attachment Details 2 0 0 0 cccccceccccccecceceeeeeeeeeeeeeeeueeeaeeeeeeeueueeeaeseeueeueueeeaeeuueeaesaueeesueueeeeaneeess 6 Mec ade EO aad aera a EAE EE ASE E EEEE E E R E seanaeraocsteceeneesaseer 7 ACY EO eea E E E E E E E namics deans 7 Associated Documents xo case ccdictepe sane athcndaccte tee nondpacdceiens ia neahs sod exabdeancadeaauuekendinasntn ded eccaadeapeuieaiteremeneecendeens 8 CLAIMANT AND ADJUSTER DETAILS TAB 1 cccccsececeececeeceneeecuceceececeneeneeeeueecaueesaneeueeeueeesaesesaneenneeneeesaeees 9 PART 1 Applicant information ieaninsssnnrechdanetemesinnnantanctienantnnncidaciedcmesheusandseabivansduntnsidarsicwes encentaacnivausianekes 9 PART 2 Auto Insurer INfOrMation cccccceceeceeceeceeeececeeceeeeceeeeeneseeeeeseeaeseeseeneeeeseeeeuseeaeeeenenneenesenness 10 Working With the OCF 18 Treatment Plan Confirmation FOr ccccccsssecceeceeeeeeeeeeaeeeeeeeeeaeeeeeeeeeas 11 Part 12 Proposed Goods and Services cccccccccssseeceeeceeeeeeeeeeaeeeceeesaeeeeeeeeseaeee
19. d 2013 05 28 Date of Accident 2010 05 05 Source Web OCF Effective Date 2012 11 01 Archival Status Not Archived You have responded to document number 130523800001 CLOSE WINDOW CREATE OCFS 2013 Health Claims for Auto Insurance Processing Privacy Policy Click the BAS button to return to the Insurer home page Depending on the decision recorded against it the plan is moved into the Adjuster Response work list lf there is any invalid or incomplete data you are returned to the form with An error notifying you that there are errors A list of errors if any on the current page The navigation buttons of error containing steps highlighted in orange 25 Insurer Manual Chapter 7 DGO Health Claims for Auic Insurance Generating and Viewing the Explanation of Benefits EOB The Explanation of Benefits EOB can be generated and viewed only after a decision has been recorded against the plan To generate an EOB Click the Review Form button 2 next to the plan you wish to open in the Adjuster Response work list under the Plans tab Click at the top or bottom of any of the steps The Explanation of Benefits window opens containing the Claim Identifier Document Number Provider Information Applicant Information Injuries Goods and Services and Reason Codes sections generated automatically based on the current plan You cannot change this information Create OCF9 H CAG CANCEL PRIN
20. e Saikali Claudia 11 0 KM Mileage Provider B A XX TT Saikali Claudia Travel Time Prow 5 Apply multiple reason codes SET CHARGED COSTS TO APPROVED COSTS Totaling Preapproved Sub total Other Goods and Services Auto Insurer Total CALCULATE To record a decision against a plan an Adjuster must either approve or decline each line item in the table and then validate the decision by submitting a final decision There are different ways of doing this To approve proposed goods and services Inthe Proposed Goods and Services table confirm and or modify the values and selections proposed by the Facility in the Cost box boxes by entering the amount you wish to approve in each of the associated active boxes below the proposed amount 21 Insurer Manual Chapter 7 068 Health Claims for Auic Insurance Part 9 Guideline Services Category Description Maximum Fee Estimated Fee Identify which Guideline is applicable PAF WAD I II 1 264 27 1 200 00 Supplementary Goods and Services Other Pre approved Services including radiology Description Maximum Fee Estimated Fee X Ray of the Cervical Spine 0 00 X Ray of the Thoracic Spine 0 00 X Ray of the Lumbar Spinal 0 00 X Ray of the Lumbosacral Spinal 0 00 Part 9 Sub total 1 200 00 Other Goods or Services Within the Guideline Requiring Insurer Approval Adjuster Code Attr Provider Reference Quantity Measure ae Response re Saikali Claudia 11
21. e read only sections as specified by the Facility during the creation of the plan Claim Identifier This section contains Applicant Name Claim Number Policy Number and Date of Accident Return this form to This section contains information about the insurance company to which the plan has been submitted Plan Identifier This section contains the Document Number which is generated by the system upon the submission of the plan by the Facility OCF Type OCF 18 or OCF 23 Date Submitted Source which indicates the method used to submit the document i e DEC PMS Web the OCF Effective Date and Archival Status 2an ___HC CANCEL EE ANT SAVE Claim identifier Retum this form to Plan identifier Applicant Name Cech Peter KOH Global Re Document Number 11020800034 Claim Number 11 1999 Eramosa Rd OCF Type 13 Policy Number PC52 Rockwood Ontario Date Submitted 2011 02 08 Date of Accident 2009 06 14 R2G 2R1 Source Web OCF Effective Date 2010 09 01 Archival Status Not Archived i Note The above three sections appear at the top of each step of the OCF Plan Review following the Summary page 4 Insurer Manual Chapter 7 Plan Details Tish even Regma The Plan Details section contains the following information Document Number This number is generated by the system upon submission of the plan TAKE OWN Owner If you work as part of a team click the sitll button This inse
22. ed goods and services for the same reason Inthe Apply multiple reason codes section click the SET REASON FOR DECLINING button to search for and select the reason code applicable to the decision To initiate the Need To Discuss In the bottom of the Tab 3 screen write your message to the Facility and associated Provider indicating the need to discuss Message To Provider Please provide more information on applicant NEED TO DISCUSS Click the damm bbeie button You then exit the OCF 23 Review and return to the Submitted work list on the Plans tab of the Insurer home page The Facility can now see the plan in the Submitted work list on his her Provider home page with the status changed to In Discussion Response Pending and can reply to your message Totalling Totalling Proposed Approved Preapproved Sub total Ged 0 hd Other Goods and Services R500 0 00 Auto Insurer Total 7 185 00 GG CALCULATE This section contains the calculation of all costs the Proposed column shows the amount proposed by the Facility and the Approved column shows the amount approved by the Adjuster The fields in the Approved column contain Other Goods and Services This field is calculated by adding up all the approved items in the Unit Cost column of Part 11 Other Goods and Services within the Guideline Requiring Insurer Approval Pre Approved Sub Total This field is calcu
23. eeeseeeseeeeesaaeeesessaaess 11 ADJUDICATING THE OCF 18 ccccccccceccecceeceeeeeeeeeeeeeeeeeeeeeaeeueueeeeeueeaeeeueeeeeaueeeesaueeeeeaueeaeeeueeeeeaneneeseneeanunaees 12 TO TAIN Sree a redness cers races sme caren pence iad E EE E A E E AE E E EA 14 Patt 13 Signat re Of INS Ol Cl isisa ea iaae Eaa Erina RAAEN naaa Eiaeia oe 15 mitiat ng Need TONS CUS Seacrest neces once cseaes desea aasa aE iaaea Ehad asset se ceeooceeneccceane 16 ADJUDICATING THE OCF 23 TREATMENT CONFIRMATION FORM cecccecseecseecseeceeeeseeuseeeseeueeueeeueeeueeeueeeuaes 20 MSTA MINI CU iret rcrs enced etee E ewe tadsiweebeaataataesnun aan 23 Peat 12 olgnaure of SUNS lioticanajua sani tenten a nnastevnbiedstexssmauiins n 24 Part 13 Signature of the Applicant sesscccsnseiceassicctescbed cetcakcduaadebecssdssnsdeeeboosesnaceesqenasbacesbeasadetedenceseeasecdes 24 GENERATING AND VIEWING THE EXPLANATION OF BENEFITS EOB 2 ccccceseceeceesceeteeeeceeeeeeeeeseaeeeesaeaess 26 WITHDRAW RESPONSE FROM AN ADJUDICATED PLAN c 0sccceeceeseetenceteneeceeceseeeeeeeteneeteueeseeeeeeeteneetsneetanes 29 j n Plealift Claim for Aul iniurancte Specifying Reason Codes Reason codes are specified in the final step of every OCF Plan Review in HCAI To search for a reason code use the ellipsis buttons 8 located in the Adjuster Response column of the tables as well as in the Apply Multiple Reason Codes section below these tables For instructions on how to se
24. er No have reviewed this plan and based upon the information provided APPROVE PARTIALLY APPROVE DO NOT APPROVE Message To Provider NEED TO DISCUSS To record a plan level approval decision 5 i j a Eji Click on either the Gamiiiiiedelet Liat or eee buttons Your selection will be validated against the individual line item decision recorded earlier A confirmation screen appears advising that your decision has been recorded Review OCF18 Claim Identifier Retum this form to Plan ldentifier Applicant Name Suarez Luis KOH Global Re Document Number 13052800011 Claim Number 445 2 Speyside Way OCF Type 18 Policy Number B amp 97654 Acton Ontario Date Submitted 2043 05 28 Date of Accident 2012 05 01 L2P 6p2 Source Web OCF Effective Date 2012 11 01 Archival Status Not Archived You have approved document number 13052800011 CLOSE WINDOW CREATE OCFS 2013 Health Claims for Auto Insurance Processing Privacy Policy Recording an decision requires that all goods and services line items have been individually approved as submitted A DAGS decision requires that some of the line items have been modified either in Cost Total Count or the applicability of HST in the associated active boxes Recording a decision requires that all individual line items total O in the Cost and Total Count associated active boxes 15 Insurer Manual Chapte
25. imated duraten of this Plan 1 weeks How many visits have you already provided 0 visits ee eae No services Apply multiple reason codes HiT CHARGED COSTS TO APPROVED COSTS SET REASON FOR DECLINING 25 00 0 00 0 00 0 00 325 28 25 0 00 Minus MOH Minus Other Insurer 7 2 Tax if applicable Auta Insurer Total CALCULATE 17 Insurer Manual Chapter 7 OGO Healih Claims for Aulo Iniurante The Facility will then be prompted to enter a reason code For example the reason code could be as shown below Adjuster decision Withdrawn Withdrawn on behalf of the claimant provider insurer or data entry centre see explanation for who withdrew A similar reason code screen also appears in the OCF 23 Review OCF18 Reason Code Look Up Select the Series that is appropriate for your decision To begin your search click Search To narrow down the search results you can supply a Category and or Reason prior to clicking the Search button Series Adjuster decision E Category Withdrawn v Reason Withdrawn on behalf of the claimant provider insurer or data entry centre see explanation for who withdrew VW SEARCH 2015 Health Claims for Auto insurance Processing Privacy When an OCF needs to be declined because of duplicate processing the reason codes could be entered as Unable to authorize administrative Administrative Duplicate form good or servi
26. ity Log for Document 06097800016 Date amp Time Description Version Actor ZO0ROSA8 13 16 Massage Joe Submitted a plan Version Massage Joe The Activity Log displays the history of activities associated with a plan such as submission date need to discuss approvals etc Date and Time This field shows the date when an activity recorded in HCAI took place Description This field shows the description of an activity recorded in HCAI Version This field shows the version number of the plan if the activity resulted in a new version Click on the version link to view the respective version of the plan Actor This field shows the name of the User who initiated the activity 7 Insurer Manual Chapter 7 068 Health Claims for Avia Insurance Associated Documents The Associated Documents section is where other documents associated with the claim are grouped and listed Each time you open a plan or invoice HCAI generates a list of documents associated with the same Claimant The Associated Documents list contains the following data columns Document This column contains the document number generated by HCAI upon the submission of a plan or invoice Type This column contains the type of a given plan or invoice OCF 18 OCF 23 OCF 21B and OCF 21C Facility This column contains the name of the Health Care Facility that submitted a given plan or invoice Status This column contains information on the stat
27. lan Click the Review Form button B next to it The Plan opens at the Summary screen HCAR User Manual Claim Identifier F Retum this form to E Pian identifier Applicant Name Zidane Zinedine KOH Global Re NEW Document Number 13011700008 Claim Number 189_abw_099 2 Speyside Way OCF Type 18 Policy Number 8765 Acton Ontario Date Submitted 20130147 Date of Accident 2012 0614 L2P 6p2 Source Web OCF Effective Date 2012 11 01 Archival Status Not Archived Plan Details Document Number 13011700008 Owner Status Approwed Message Log Here is a list of messaging associated with this document There are no messages Click the Aksi button beneath the Document Number in the Plan Details section A message appears asking you to confirm withdrawal Click lt OK gt in response to this message This returns you to the Plan The status of the Plan in the Plan Details section on the Summary page is changed to Review Required and the Plan is moved to the Plans Work In Progress work list Review OCF18 HCA ae 1 1a 5 j User Manual CANCEL j PRINT SAVE Claim Identifier Retur this form to E CEE i Applicant Name Zidane Zinedine KOH Global Re NEW Document Number 13011700008 Claim Number 189 abw_099 2 Speyside Way OCF Type 18 Policy Number 8765 Acton Ontario Date Submitted 2013 0117 Date of Accident 2072 06 14 L2P 6p Source Web OCF Effective Date 2012 11
28. lated by adding up all the approved items in the Estimated Fee columns of Part 9 Guideline Services Auto Insurer Total This field is calculated by clicking the Sieh button which adds up all the Approved fields in the Totalling section 23 Insurer Manual Chapter 7 068 Health Claims for Auic Insurance Part 12 Signature of Insurer Part 12 Signature of Insurer Please confirm whether you waive the requirement of the applicant s signature Use the decision buttons to submit your decision If applicable provide a message to the provider Insurers are advized not to waive the claimant signature unless they are in possession of a signed OCF 1 Adjusters First Name Rata Is the applicant s or substitute decision maker s signature waived by the insurer jy have reviewed this Treatment Confirmation Form and based upon the information provided confirm that the policy referred to in Part 2 was in force atthe time ofthe lt accident SUBMIT DO NOT APPROVE O Approve O Partialy Approve O Do Not Approwe Message To Provider NEED TO DISCUSS a _ a H CTE SAVE SUMMARY 4 2011 Health Claims for Auto Insurance Processing Privacy Policy This section contains fields to confirm whether the Insurer requires the Applicant s signature whether the policy was in force at the time of the accident and a button to validate and record the approved or declined plan items in associatio
29. n required to make a decision on the plan In Review Locked by last name first name when the Take Ownership button is clicked Privacy This field is set by the Information Security Administrator ISA in the event that the Claimant Applicant is disputing his her privacy information pursuant to PIPEDA 5 Insurer Manual Chapter 7 068 Health Claims for Auic Insurance Additional Attachment Details HCAI provides the ability for a Facility or associated Provider to flag when attachments are sent by mail or fax If the Facility or Provider clicks the flag indicating information will follow the OCF the Additional Attachment Details box will display on the Summary tab of the plan or invoice Only Users with Adjuster level permissions will see the Additional Attachment Details box on the Summary tab of a plan or invoice This box allows the Adjuster to enter the date he or she received the attachment s Once an Adjuster has entered the date the attachments were received the SABS timeline clock is reset and a new version of the document is created Remember the clock is only a guide that provides time management assistance for the Adjuster It does not preclude the Adjuster from making a decision in any timeframe they deem to be in accordance with the SABS guideline Review OCF18 CANCEL HCAR User Manual n rm PRINT SAVE Plan identifier Document Number 13060300007 fee Return this form
30. n with Part 11 Select Yes to confirm that you waive the applicant s signature and No if you do not Select Yes to confirm that there was a valid policy in force that will correspond to the applicant s claim or No if there was not Part 13 Signature of the Applicant Part 13 Signature of Applicant is the applicants or substitute decision maker s signature on file Ne Applicant s or Substitute Decision Maker s First Name Peter Applicant s or Substitute Decision Makers Last Name Cech Signed Date Was the applicant s or substitute decision makers signature waved by the insurer This information is read only having been specified by the Facility In the Signature of Insurer Section you will be asked to confirm that the Policy referred to in Part 2 was in force at the time of the accident You will answer the question and hit submit to log your decision If other goods and services were completed in Part 11 you will approve partially approve or do not approve these items 24 Insurer Manual Chapter 7 Hic TAL Health Claims for Auic Insurance Successful submission lf there are no errors or incomplete data your approval decision is submitted The default confirmation screen then appears Review OCF23 Claim identifier Retum this form to Plan Wentifier Applicant Name Voka Hans Document Number 13052800001 Claim Number 78934 99 87 OCF Type 23 Policy Number RE 86354 Date Submitte
31. nic Kian Clinic Kian Clinic Kian Clinic Acme Rehab The Healthy Health Clinic gt Status Review Required Review Required In Discussion Response Sent Review Required Declined Review Required Review Required Approved Review Required In Discussion Response Sent 2009 06 30 2011 02 08 2011 05 02 2011 03 03 2011 03 03 2011 0303 2011 03 03 2011 08 03 2011 10 11 Amounts 163 00 110 00 1 730 00 3260 00 1 730 00 260 00 330 00 1 250 00 107 35 Insurer Manual Chapter 7 068 Health Claims for Auic Insurance Claimant and Adjuster Details Tab 1 In the Tab 1 screen of the OCF Plan Review you can view the Claimant details as specified by the Facility and compare these details with the Claimant information provided by the Insurer If you have been granted the appropriate HCAI roles you can also link unlink and update the Claimant In addition to assigning and reassigning Adjusters transferring the claim between branches of the Insurer can also be accomplished from this screen PART 1 Applicant information Review OCF1 SUMMARY 4 i HCA User Manual CANCEL Claim identifier Applicant Name Diaz Carmen Claim Number 0203 Policy Number CD_01 Retum this form to KOH Global Re 2 Speyside Way Acton Ontario Plan identifier Document Number _ PRINT SAVE gt 09070900018 Plan Number OCF Type 18 Date of Accident 20
32. ods and Services and the list of Other Pre approved services including Radiology The list includes Category PAF MIG Supplementary Goods and Services and Other Pre approved services including Radiology Description This column contains the description of the PAF MIG and the supplementary goods and services and the x ray descriptions Views This column contains information on the required number of X ray views Maximum Fee This column contains the maximum fee as per the Superintendent s guideline Estimated Fee This column contains the cost of the pre approved good or service which the Facility is billing for Part 9 Guideline Services Category Description Maximum Fee Estimated Fee identify the Guideline which is applicable PAF WAD Vil 1 264 27 1 200 00 Supplementary Goods and Services Other Pre approved Services including radiology Code Description Views Maximum Fee Estimated Fee 35010 X Ray of the Cervical Spine Not Selected 0 00 35C10 X Ray of the Thoracic Spine Not Selected 0 00 35C10 X Ray of the Lumbar Spinal Not Selected 0 00 35C10 X Ray of the Lumbosacral Spinal Not Selected 0 00 Part Sub total 1 200 00 To address an incorrect form submission e g the absence of coverage for an OCF 23 submitted prior to September 1 2010 the Adjuster must deny the entire OCF 23 by clicking the SET REASON FOR DECLINING button in Part 11 To decline a form that has been received in error that is received afte
33. r 7 ry fet y a Plealift Gl or Aule Iiniurante Initiating Need To Discuss The Need to Discuss functionality facilitates the interaction between the Facility and the Adjuster in cases when a discussion over the proposed plan is required When initiated it provides a mechanism for the Adjuster User to type text in a message box and send the message to the Facility Each message item is recorded in the Message Log displayed on the Summary page of the plan To send a message to the Facility and associated Provider Write your message to the Facility and or associated Provider s indicating the need to discuss This message box appears in the bottom of Tab 5 for OCF 18 or Tab 3 for OCF 23 Message To Provider 7 NEED TO DISCUSS Click the button You then exit the plan Review and return to the Submitted work list on the Plans tab of the Insurer home page The Facility User can now see the plan in the Submitted work list on his or her home page with the status changed to In Discussion Response Required and can reply to your message 16 Insurer Manual Chapter 7 HICA Health Claims for Avia Insurance Scenario 1 Facility Provider wants to take back a form that has been submitted to the Insurer but has not yet been adjudicated When a Facility and or associated Provider wants an Adjuster to withdraw a form either because of duplicate processing or because the treatment is no longer required the Facility or a
34. r September 1 2010 go to Part 12 answer No to the policy in force question and click FOO NOT APPROVE eee Part 11 Other Goods or Services within the PAF Guidelines Requiring Insurer Approval This section of the OCF 23 will only display for forms created for Claimants who suffered injuries prior to September 1 2010 GS Ref The recorded number of a given good service Code This column contains a CCI or GAP code and the description of the good or service Attribute If applicable Provider Reference This column contains the name of the Provider which is a link Click on the link to open a separate window to view the Provider details Provider Name Provider Profession and Registration Number Quantity Measure This column contains the quantity of the good service to be delivered per visit as proposed by the Facility and the unit of measure for this quantity 20 Insurer Manual Chapter 7 O60 Health Claims for Auic Insurance Cost This column contains the cost per good or service unit as proposed by the Facility It has an active box for the User to confirm or K e amount submitted by the Facility Adjuster Response The ellipsis box a opens the Adjuster reason code responses If the full cost is not being accepted an Adjuster reason response must be selected Part 44 Other Goods or Services Within the Guideline Requiring Insurer Approval Provider Reference Quantity Measure D bock Respons
35. rts your name to the left of the button and changes the button to RELEASE OWNERSHIP This action is not required by those who do not work as part of a team Once a User has taken ownership of a plan the system flags the plan and other Users are able to see that the plan is currently being worked on This plan is also marked as locked by in the Work In Progress work list on the Insurer home page Clicking on the button removes the flag from the plan clears your name and changes the button back to Take Ownership Status This field shows the status of the current plan which can be one of the following Unmatched when the plan has not been matched to a Claimant Unassigned when the plan has been matched to a Claimant but Adjuster is not assigned Review Required when you are currently working on the plan In Discussion Response Sent when you initiated Need to Discuss and opened the plan from the Submitted work list under the Plans tab of the Insurer home page In Discussion Response Received when if the Facility has responded to the Need to Discuss for the plan Approved when you have recorded an approval decision against the plan Declined when you have recorded a do not approve decision against the plan Partially Approved when you have recorded a partial approval decision against the plan Pending when the plan has been placed in pending status while you await further informatio
36. s OCF 18 Review This consists of seven screens the Summary page which is generated automatically when the form is submitted and the six Tabs steps of the plan which have been completed by the Facility and are presented in read only format Only two of the five steps require any action or response Tab 1 where Claimant and Adjuster information can be updated and Tab 5 where decisions are recorded OCF 23 Review This consists of five screens the Summary tab which is generated automatically when the form is submitted and the four Tabs steps of the plan which have been completed by the Facility Only two of the three steps require any action or response Tab 1 where Claimant and Adjuster information can be updated and Tab 3 where decisions are recorded Tabs 2 and 4 are presented in read only format 2 Insurer Manual Chapter 7 068 Health Claims for Auic Insurance Launching OCF Plan Review Select the Plans tab at the top of the Insurer home page This takes you to the Plans Work In Progress work list KOH Global Re HCR INVOICES CLAIMS SEARCH Y MANAGE 7 User Manual eee F 4 in ll Forms E Jexact Match E Advances LOGOUT ADJUSTER RESPONSE 4 PENDING i Plan Management Work In Progress IEAA KOH Global Re Work In Progress 1 of 2 The following tems have not been adjudicated View 10 items 42 Next gt k P Document P Claim P Claimant P OCF Type P Statu
37. s DaysLeft P Date Submitted 11050300083 1999 Ferguson OCF Submitted 2017 03 03 11030300081 1999 Ferguson OCF18 Review Required 2011 03 03 11030200009 517 Ronaldo DCF18 Review Required 2011 0202 11030200013 0203 Disz DCF18 Review Required 2011 03 02 11050200015 feg7eg Singh OCF18 Unmatched 2017 05 02 11050300080 Tif Diaz OCF23 Unmatched 2017 03 03 11030200011 Diaz OCF23 Unmatched 2011 0202 View 10 items 42 Next gt 2011 Health Claims for Auto Insurance Processing Privacy Policy Change Password Navigate to the plan you are interested in working with by locating it in the Work In Progress work list and click on the Review Form button next to it If HCAI has automatically linked the applicant details on the plan with the Insurer s Claimant information the OCF Plan Review opens to the Summary tab of the selected plan document by default Otherwise you are taken to the Claimant Match screen where you can attempt to match the Claimant manually For more information on matching Claimants to plans see Chapter 6 Claim and Claimant Management 3 Insurer Manual Chapter 7 is i T j TL Health Claims for Auic Insurance Summary Tab The Summary tab is generated automatically upon the submission of a plan by the Facility It allows for a quick overview of the plan and related documents while showing the document s transaction history and its current state In the upper part of the page there are thre
38. ser to confirm or modify the amount submitted by the Facility Total Cost This column shows the total cost of delivering the goods or services HCAI calculates this value by multiplying the Unit Cost by the Total Count Proposed Tax This column indicates the applicability of HST to the selected goods or services as proposed by the Facility There are two associated active boxes for the User to confirm or modify the proposed tax assessment as submitted by the Facility Adjuster Response An ellipsis button amp is available to assist in searching for a reason code in the event you decline the item 11 Insurer Manual Chapter 7 0600 H alih Claima for Aula Iiniurancte Adjudicating the OCF 18 To record a decision against a plan you must either approve or decline each line item in the table and then validate the decision by submitting a final decision To approve proposed goods and services In the Proposed Goods and Services table confirm and or modify the values and selections proposed by the Facility in the Unit Cost Total Count Proposed Tax box by entering the amount you wish to approve in each of the associated active boxes below the proposed amount OR if you wish to approve the plan as submitted without any modifications in the Apply multiple reason codes section Click SET CHARGED COSTS TO APPROVED COSTS Part 12 Proposed Goods or Services Requiring Insurer Approval Estim
39. ssociated Provider must contact the Adjuster and request that the OCF be declined The Adjuster will click the Review OCF18 O SUMMARY identifier Applicant Witchson Mitch Claim Number 10132011 Policy Number 20111310 Date of Aoede 2011 10 10 Associated Documents Results Associated Documents 1 of 1 SET REASON FOR DECLINING button HCA F User Maral __ _ a PRINT TAY D pamai 14082800 120 OCF Type 18 Date Submitted 2074 08 26 Source Web OCF Effective Date 20140711 Archival Status Not Archived SHOW ARCHIVED OCOOUMEHT S Showing associated documents which are active To show archived documents click Show Archived Documents CEI 8 OCFZIB CEI 8 OCF2IC 1102040024 OCF 110302000 OCF21B 110303008 OCF23 1100S OCF21C iiD OCF21B 1O OCF210 1108020000 8 OCF23 Kian Clinic Kian Clinic Kian Clinic Kian Clinic Kian Clinic Kian Clinic Kian Clinic Acme Rehab The Healthy Health Chine b Status Review Required Review Required In Discussion Response Sent Review Required Declined Review Required Review Required Approved Declined Review Required 2008 08 30 2009 08 30 201 1 02 08 2011 02 02 201 1 02 03 201 1 003 201 1 0203 2011 02 03 201 1 08 03 2075 0316 3163 00 710 00 31 720 00 200 00 1 720 00 320 00 280 00 320 00 31 720 00 375 00 Cost Total Total Pr Count Cost 25 00 1 27400 i af a posed Adjuster 1 00 HR Est
40. tton B next to each good or service to search for the reason code and to add it to the Adjuster Response column 12 Insurer Manual Chapter 7 0E00 Health Claims for Aula Insurance OR if you wish to deny all proposed goods and services for the same reason in the Apply multiple reason codes section Click the SET REASON FOR DECLINING to specify the reason code common for all goods and services Part 12 Proposed Goods or Services Requiring Insurer Approval Estimate Day Projected GS Code Attr Provider Reference Quantity Measure Cost Total Total Proposed Adjuster Ref Count Response 1222 02 Pp 1 00 HR 25 00 1 Assessment exam 0 00 lo Estimated duration of this Plan 1 weeks How many visits have you already provided 0 visits Has the applicant or substitute decision maker confirmed consent by initialing the proposed goods and services No Yes Apply multiple reason codes SET CHARGED COSTS TO APPROVED COSTS SET REASON FOR DECLINING Adjuster Proposed Approved Calculated Respo nse Total Count 1 0 Sub total 25 00 0 00 Minus MOH 0 00 Minus Other dip p 0 00 Tax if applicable 3 25 Auto Insurer Total 28 25 0 00 CALCULATE 13 Insurer Manual Chapter 7 Plealift Claim for Aul Iiniurancte Totalling This section displays a summary of the total cost of the approved line items in the Proposed Goods and Services table The Proposed column shows the amount
41. us of a given plan or invoice Approved Partially Approved Denied Need To Discuss Pending In Review Locked by Adjuster Review Required Submitted and Responded Date Sent This column contains the date a given plan or invoice was submitted Proposed Amount This column contains the cost of treatment proposed by the Facility under a given plan or invoice Approved Amount This column contains the amount approved by the Adjuster for a given plan or invoice You can sort the items in the Associated Documents list by clicking on the header of the column that you want to sort Clicking a second time reverses the sort order To open a plan or invoice from the Associated Documents List click on the document number The button is available regardless of whether any related OCFs have been archived clicking on this button will enable presentation of the associated OCFs that have been archived when appropriate Associated Documents Results Associated Documents 1 of 1 Showing associated documents which are active To show archived documents click Show Archived Documents SHOW ARCHIVED DOCUMENTS Proposed Document 09063000002 09063000011 110206800024 11030200016 11030300060 11030300065 11030300087 11030300066 11060300004 11101100040 H Type OCF218 OCF21C OCF23 OCF21B OCF23 OCF21C OCF21B OCF21C OCF23 OCF1 CANCEL CREATE OCF Facility Kian Clinic Kian Clinic Kian Clinic Kian Cli
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