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OCF 21 - Auto Insurance Standard Invoice User Manual

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1. o for goods and services Enter the total amounts received or estimated to be payable to you on this invoice for goods and services from other insurance sources e g Ministry of Health and Long Term Care and Extended Health Care plans to which the applicant is eligible 11 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 Amounts may be signed or unsigned When you are indicating the amount payable or not payable from an Other Insurer e Use a negative sign to indicate the amount you have received or will receive directly from the collateral source or applicant This will allow collateral insurance payments to be subtracted from the sub total to determine the amount owed by the automobile insurer e Use a positive sign or leave unsigned to indicate the amount previously identified for payment by another insurer but subsequently ruled ineligible This will allow you to add the unpaid amount to the auto insurer s invoice Account Activity Since Last Invoice Account Activity Since Last Invoice if Interest is being charged 120 50 Payment Received from Auto Insurer 120 50 The insurer shall pay interest on overdue outstanding balances in accordance with the Statutory Accident Benefits Schedule This section is required only if you are charging interest o
2. Refer to Appendix B for a list of CCI codes and corresponding Attribute Codes For Goods Administration and other codes GAP not included in the CCI code set enter a valid GAP code Refer to Appendix C for a list of valid GAP codes Refer any questions regarding goods and service coding to your provider association or access the website at www hcaiinfo ca under Auto Insurance Resources gt Statutory Accident Benefits gt Codes and Appendices Provider Reference Enter the Provider Reference code of the professional rendering the service or prescribing the good When a service is provided by more than one health care professional enter all Provider Reference codes separated by commas 25 Quantity and Measure Enter a number and the unit of measure to indicate the quantity of goods or services rendered on a single date of service For time based services the unit of measure is an hour Any portion of an hour is entered as a decimal e g 15 minutes is represented as 25 Hr For procedure based services the unit of measure is a procedure and is always a whole number e g a chiropractic manipulation is represented as 1 Pr Refer to Appendix F for valid Unit Measure Codes and a Conversion Table to convert minutes to hours Reimbursable Fees Within the PAF Guidelines Reimbursable Fees Within the PAF Guidelines Tum Attribute PAF WAD II Block Fee 1 W2 X Rays Cervical Spine 3 SC 10 PAF WAD II Block F
3. Applicant Information Smith To be completed time Miik Name by the Solce Jonathan James Arkiress 123 Main Street cw Postal C ode Toronto MOM OMO If this is a second or subsequent invoice you do not have to fill out all fields of this section Provide only the full name and date of birth If an applicant s address has changed provide the new address Part2 Insurance Company Information Company Name Cty or Town of Branch Office if applicable Part 2 North York Insurance Adjuster Last Name Adjuster Firs Name Company Information Adjuster Telephone Adjuster Fax 416 555 5555 416 555 5555 Name of policy nolder same as Polcy Holder Last Name Policy Holder Firet Name po cart Smith Jessica This is the name of the insurance company and branch responsible for processing and paying the invoice Completing the adjuster information fields if known will assist insurers to process the invoice more quickly The name of the Policyholder will assist insurers to match the accident with the policy thus ensuring quick processing of the invoice Part 3 Invoice information For previously approved goods and services please complete the following Plan Date YYYYMMDD Approved Previously Type of Plan or Pre approved Framework Amount Billed Plan Number 71 Treatment Plan OCF 18 Part 3 L1 Assessment Plan OCF 22 Invoice e CCR 9042 CJ p
4. AISI number Payee Number If you are a regulated health professional enter your college registration number here Unregulated providers must obtain an AISI provider registration number by registering at www hcaiinfo ca Providers that already have an AISI Provider Number do not need to register again for the new invoice Unregulated providers enter the AISI Provider Number in this field NB Future implementation of the HCAI system may eliminate the need for an AISI number Conflict of Interest and Signature of Health Professional Read the Conflict of Interest statement and check the appropriate box Signature of Health Professional Authorized Facility Signatory If the invoice is submitted by a regulated health professional or social worker the regulated health professional or social worker provides the signature When unregulated providers facilities register they indicate who is authorized to submit invoices on behalf of the facility The inclusion of a revised statement of understanding identifies for the Health Professional or Social Worker the range of specific uses that will be made of information related to providing services to injured auto insurance claimants Version A You can use Version A only when billing for goods and services that have been requested and approved through an OCF 18 OCF 22 or OCF 11 Injuries providers goods and services are detailed on the plan there is no need to duplicate that information o
5. amount previously identified for payment by another insurer but subsequently ruled ineligible This will allow you to add the unpaid amount to the auto insurer s invoice Account Activity Since Last Invoice Account Activity Since Last Invoice if Interest is being charged Prior Balance Payment Received from Auto Insurer 120 50 The insurer shall pay interest on overdue outstanding balances in accordance with the Statutory Accident Benefits Schedule This section is required only if you are charging interest on this invoice It provides details on Overdue Amounts which are the basis for Interest charges Enter Prior Balance the Auto Insurer Total from your last invoice and subtract Payments Received since your last invoice to calculate Overdue Amount 20 Totals Sub Total 217 50 Other Insurer 1 2 100 00 GST if applicable PST if applicable Auto Insurer Total 122 91 In the Totals section Sub Total is the sum of the cost of all goods and services included on all pages of this invoice MOH is the sum of all Ministry of Health and Long Term Care amounts This amount is taken from the Other Insurance amounts table column 1 MOH 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 Oth
6. for the period of this Treatment Plan Estimate Day Projected Description Code Attribute Total Total Cost Count Cost Initial Assessment 2 22 02 45 00 1 45 00 Claim Form OCF 18 7 8J 30 LB 42 50 1 42 50 Mobilization 1 91 01 mm Refer to the pre approved plan for each good and service reference number G S Ref Enterthe Provider Reference from the pre approved plan or the Provider table above atthe intersection of the date of service and the G S Ref indicating the provider who rendered or prescribed the service or good Month yyyy mm Enter the month the services or goods were rendered in the format yyyy mm e g 2003 11 Each calendar page represents one month Additional pages can be used for additional months Provider Enter in the grid the provider reference letter e g A B C of the individual who rendered the service or prescribed the good under the appropriate dates The only entries that should appear on the calendar are upper case alphabetic letters 10 GST and PST The only valid entry in the GST and PST columns is blank does not apply or a check mark 4 applies Amounts associated with GST and PST are indicated as totals and are not required at the detail level Cost Day All goods or services on a single row must have the same cost per
7. N A not applicable The exception to this is the Activities of Normal Living Intervention ANLI for which the hourly rate of the provider must be entered The box for Insurer Use may be used by insurers to total goods and services by Provider Type for statistical reporting 24 Goods and Services Rendered Goods and Services Rendered PAF providers are required to declare the information requested below on every treatment service and good delivered Failure to provide this information may delay payment Date of Servi We i ww MM Db Description Code Atwibute Reference 2003 06 Initial Assessment Z2 02 A 1 pr 2003 06 X ray cervical spine 8C 10 pr 2003 08 Manipulation 2T pr Quantity Measure 2003 10 Manipulation 91 712 pr 2003 13 Manipulation 81 12 pr 2003 13 Exercise 22 02 hr 2003 15 Manipulation 1 72 pr 2003 15 Exercise 22 02 hr Providers are required to declare the information requested on every treatment service and good delivered Failure to provide this information may delay payment Date of Service Enter the date the good or service was rendered in the format year month day e g 2003 11 15 Description Enter a brief description of the good or service provided Code and Attributes For those services representing a diagnostic therapeutic or health care support intervention enter a valid CCI code and attribute if required
8. OCF 21 AUTO INSURANCE STANDARD INVOICE USER MANUAL March 2006 INDEX DOCUMENT CHANGE HISTORY INTRODUCTION OCF 21 AUTOMOBILE INSURANCE STANDARD INVOICE VERSION A VERSION B VERSION C 15 23 Document Change History Date Description of Change Reason 20030930 Initial Publication 20031215 Invoicing for PAF Extension Visits PW2EV 20040204 Clarify Payee Facility Number and Payee Number inclusion of social worker 20050214 Revised Payee Information For consistency with revised OCF forms 01 Dec 04 20060301 Revised Further information Who Completes this Redirects users to HCAI website for further Form Invoice Information information and reflects removal of DACs and Changes are underlined Introduction Who should use this manual This User Manual is designed to assist both health care providers and automobile insurers in the completion of the OCF 21 Auto Insurance Standard Invoice Other manuals are available to assist in the completion of OCF 3 Disability Certificate OCF 18 Treatment Plan OCF 22 Application for Approval of an Assessment or Examination OCF 23 Pre Approved Framework Treatment Confirmation Form OCF 24 Pre Approved Framework Discharge amp Status Report Facilities and health care providers dealing with victims of motor vehicle accidents are required to use these forms Both rehabilitation health care providers and automobile insurers have de
9. Refer any questions regarding injury coding to your provider association or access the website at www hcaiinfo ca under Auto Insurance Resources gt Statutory Accident Benefits gt Codes and Appendices Providers Provider Type List Providers Requiated Unregulated Hourly Rate For insurer s College Reqistration AIS Number If Firet Name Number applicable or blank Provider details are not required F they are the same as those on an approved plan Refer to the User Manual at wan bealinfo ca for coding Providers need only be entered if there has been a change in the providers since the plan was approved Health providers Social workers are assigned an upper case alphabetic letter i e the Provider Reference The Provider Reference letters are used to cross reference information on previously approved plans and the Automobile Insurance Standard Invoice Assign a Provider Type code for each of the health professionals rendering services or prescribing goods Refer to Appendix E for a complete list of Provider Type codes If you are a regulated health professional or social worker provide your college registration number and leave the AISI number blank If you are an unregulated provider you can obtain an AISI number by registering at www hcaiinfo ca NB Future implementation of the HCAI system may eliminate the need for an AISI number If appropriate enter the hourly billing rate for each of the prov
10. ar D 4 Attach Version C For all other invoices attach Version B Invoice number is the space for your own internal invoice number It is optional Indicate that this is a First Invoice if you are beginning to treat this applicant for injuries sustained in a new motor vehicle accident or in relation to a new Treatment Plan Indicate Yes to the Last Invoice question if the applicant has been discharged If the invoice is for pre approved services please check the appropriate type of plan or PAF and indicate the date and number of the plan Part 4 Payee Information Fadly Name appicabie AISI Factity Number if applicabie Part 4 2222 Payee Payee Lasi Name Payee Firet Name Payee Number F appicabie information Bernsen Address 234 Second Avenue East City Province Postal Code Telephone Number Fax Number Email Acdress bberrington famcare ca El wish to declare that nave no conflicts of Interest relating to this invoice and have determined after making reasonable Inquiries that there are no conflicts of interest relating to tnis invoice on the part of any person who referred the applicant to a person who provided goods or services referred to In this Invoice or C t am aeciartng the following conficts of interest relating to tnis Invoice certify that the information provided is true and correct understand that it is an offence under the Insurance Act to knowingly make a fa
11. ccident Benefits User Manuals Contact your professional association for any questions relating to coding of injuries interventions health care services and guidelines as they relate to your specific practice Samples of Completed Sections of the Forms The samples 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 21 Automobile Insurance Standard Invoice Background The Automobile Insurance Standard Invoice AISI is to be used when billing automobile insurers for medical and rehabilitation goods and services assessments and examinations lt is used for accidents that occur on or after November 1 1996 Any health care provider billing an Ontario automobile insurer to treat the victim of a motor vehicle accident for benefits under the Statutory Accident Benefits Schedule of the nsurance Act should use this form The Standard Invoice was devised to provide more efficient processing of invoices better information about medical and rehabilitation health services being provided and increased accountability in the automobile insurance sector There are three distinct versions for the standard invoice A B and C The circumstances under which each version must be used are set out below This form may not be materially altered in other words the document cannot be changed in any manner If this document is materially altered it may be consid
12. day Enter the cost per day in this column e g 20 00 for a 1 2 hour service each day If a service or good has a different cost per day it must be entered as a second row with the same G S Reference number e g 40 00 for a 1 hour service for each day Total Count Service The Total Count is a count of all dates when this good or service was prescribed or rendered at the cost indicated for this row If 6 therapy sessions are indicated for this row in the calendar Total Count is 6 Total Cost Service The Total Cost column for each row is equal to Cost Day times Total Count i e the total for this service or good at this rate for the month Sub Total Count The sub total of Total Count is the sum of all counts of all goods and services rendered for the month It is calculated by summing the Total Count column and should be equal to the number of calendar dates of service with a provider in the box Sub Total Cost The sub total of Total Cost is the sum of all costs for all goods and services rendered for the month It is calculated by summing the Total Cost column and should be equal to the cost of all goods and services by all providers for all dates of service for the month Other Insurance Amounts MOH J Insurer Chirac O Phiemp 10000 WassgeTery HENCE 500 Other Service Type Please Specify Other Service Type on this invoice 100 00 o e z Q vo a k a
13. dicated a tremendous amount of time and thought to the revision of the Auto Insurance Standard Invoice and other forms These forms will improve the accountability of all parties streamline the process of delivering health care services to applicants and enhance communication between insurers and health care professionals The forms are designed to facilitate a clear understanding of the interactions amongst an injured motorist a health care professional and an insurer through the use of common terms and language All forms use the national coding standards the nternational Statistical Classification of Diseases and Related Health Problems Tenth Revision Canada ICD 10 CA to identify injuries and the Canadian Classification of Health Interventions CCI to classify health care services and procedures 1 ICD 10 CA and CCI are copyright products of the Canadian Institute for Health Information CIHI and may not be changed without the Institute s express permission What is in this manual The manual provides detailed instructions for completion of the fields in the order in which they appear on the forms The appendices include tables of standardized codes and descriptions for the various codified fields used on the forms Where can get more information The manual will be updated from time to time The latest updates to the manual can be downloaded from the website www hcaiinfo ca under Auto Insurance Resources gt Statutory A
14. ee 2 Supplemental Goods and or Services P W2 SC Refer to the User Manual at www hcalinfo ca for coding The amounts shown in the example for the Block 1 and 2 fees and OT hourly fee are accurate from November 1 2003 until further notice For the period October 1 October 31 2003 inclusive these amounts are Block 1 fee 300 Block 2 fee 540 OT hourly rate 120 Use this box to record fees that are pre approved in the relevant PAF Guideline Description Code and Attribute Enter a description and code of the reimbursable service Attribute codes in this section are required for all radiology codes Refer to Appendix D for a complete list of PAF block codes Cost Enter the appropriate cost according to the Pre approved Framework Guideline 26 Other Reimbursable Goods and Services Approved by the Insurer Other Reimbursable Goods and Services Approved by the Incurer Dato of Service Decoription n Peter io Ae User Mamae www ica nfo ca tor coding Other Goocc and Serviosc Total The amounts shown in example for the Block 1 and 2 fees and OT hourly fee are accurate from November 1 2003 until further notice For the period October 1 October 31 2003 inclusive these amounts are Block 1 fee 300 Block 2 fee 540 OT hourly rate 120 Use this box to record fees for services permitted by the relevant PAF Guideline but which require insurer approval This includes fees for PAF Extensi
15. er Insurer 1 2 is the sum of all amounts received or payable to you from other insurers This amount is taken from the Other Insurance amounts table column 2 column 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 GST is the total GST for all goods and services included in this invoice Goods and services to which GST applies are identified with a check mark in the GST column PST is the total PST for all goods and services included in this invoice Goods and services to which PST applies are identified with a check mark in the PST column Interest is the total amount due for overdue outstanding balances and is based on the Overdue Amount calculated in the section Account Activity Since Last Invoice Interest is calculated in accordance with the Statutory Accident Benefits Schedule Auto Insurer Total is the sum of all amounts in this section 21 Make cheque payable to Family Care Clinic Other Information Make cheque payable to Enter the name of the facility clinic or person to whom the cheque should be made payable Other Information This space may be used to communicate any additional information that will help the insurer process the invoice For Insurer Use For insurer s use only Reviewed By AppovedB
16. ered incomplete and the insurer may not accept the form When to use Version A You can use Version A only where an auto insurer has approved the goods and services that are being billed Insurer approval is requested using the following forms e a Treatment Plan OCF 18 e a Designated Assessment Centre Referral Plan and Summary Form OCF 11 e an Application for Approval of an Assessment or Examination OCF 22 198 Since the approved plan has already described the injury health provider and goods and services information there is no need to duplicate that information Version A works in conjunction with the approved plan to indicate services provided and remuneration owing When to use Version B Version B must be used when billing an auto insurer for goods or services that have not been previously approved It may not be used for billing Pre approved Frameworks use Version C Version B requires the provider to describe all the injury health provider and goods and services information Providers have the option of using either Version A or B if an OCF 18 Treatment Plan OCF 11 DAC Assessment Plan or OCF 22 Application for Approval of an Assessment or Examination has been approved When to use Version C Version C must be used when billing for services rendered through a Pre approved Framework This includes billing for PAF Extension Visits approved by the insurer on an OCF 24 Who completes this form The Applicant
17. hen you are indicating the amount payable or not payable from an Other Insurer e Use a negative sign to indicate the amount you have received or will receive directly from the collateral source or applicant This will allow collateral insurance payments to be subtracted from the sub total to determine the amount owed by the automobile insurer e Use a positive sign or leave unsigned to indicate the amount previously identified for payment by another insurer but subsequently ruled ineligible This will allow you to add the unpaid amount to the auto insurer s invoice 28 Account Activity Since Last Invoice Account Activity Since Last Invoice if Interest is being charged Prior Balance Payment Received from Auto Insurer 2Overdue Amount e insurer shall pay interest on overdue outstanding balances as required by the Statutory Accident Benefits Schedule This section is required only if you are charging interest on this invoice It provides details on Overdue Amounts which are the basis for Interest charges Enter Prior Balance the Auto Insurer Total from your last invoice and subtract Payments Received since your last invoice to calculate Overdue Amount Totals Sub Total 1 047 75 Other Insurer 1 2 100 00 GST F applicable 280 PST if applicable 320 N A 90340 In the Totals section e Sub Total is the sum of the cost of all goods and services included on all pages of this invo
18. ice e MOH is the sum of all Ministry of Health and Long Term Care amounts This amount is taken from the Other Insurance amounts table column 1 MOH 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 Other Insurer 1 2 is the sum of all amounts received or payable to you from other insurers This amount is taken from the Other Insurance amounts table column 2 column 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 29 e GST is the total GST for all goods and services included in this invoice Goods and services to which GST applies are identified with a check mark in the GST column e PST is the total PST for all goods and services included in this invoice Goods and services to which PST applies are identified with a check mark in the PST column e Interest is the total amount due for overdue outstanding balances and is based on the Overdue Amount calculated in the section Account Activity Since Last Invoice Interest is calculated in accordance with the Statutory Accident Benefits Schedule e Auto Insurer Total is the su
19. iders listed If you will not be billing for the proposed services using an hourly rate enter N A The box for Insurer Use may be used by insurers to total goods and services by Provider Type for statistical reporting Goods and Services Each calendar page represents one month of goods or services rendered Column headings 1 through 31 across the top of the table represent the dates of service from the first of the month to the thirty first of the month If you are invoicing for goods or services which span across 2 months complete one Version A for each calendar month Totals need to be calculated on only the last calendar page Details of the good or service descriptions and CCI GAP codes are not required on Version A These are already provided on the approved plan You need only enter the Goods Service Reference number from column 1 of the approved plan in the first column of the calendar table For each date a good or service was rendered indicate the reference number of the Provider column 1 from the Provider Table A or B or C etc who rendered the service or prescribed the good Goods Service Reference Enter the goods and services reference number from the previously approved plan e g 1 2 3 Example from an approved Treatment Plan OCF 18 Part 12 Proposed Goods and Services Tothe extent possible this Treatment Plan should indude all goods and services G S contemplated by the Health ProfessionalF acility
20. ies are identified with a check mark in the GST column PST is the total PST for all goods and services included in this invoice Goods and services to which PST applies are identified with a check mark in the PST column Interest is the total amount due for overdue outstanding balances and is based on the Overdue Amount calculated in the section Account Activity Since Last Invoice Interest is calculated in accordance with the Statutory Accident Benefits Schedule Auto Insurer Total is the sum of all amounts in this section 13 Make cheque payable to Other Information Make cheque payable to Enter the name of the facility clinic or person to whom the cheque should be made payable Other Information This space may be used to communicate any additional information that will help the insurer process the invoice For Insurer Use For insurer s use only Reviewed By Approved By S Payee Name Payment Amount This table is provided for insurers review approval and payment processes and to assist with communication with accounting functions The grand total is broken down to allow sub ledgering of interest separately from medical payments 14 Version B Version B must be used when billing an auto insurer for goods or services that have not been previously approved It may not be used for billing Pre approved Frameworks use Version C Version B requires the provider to describe all the injury hea
21. ist the injury requiring the most services Refer to Appendix A for further information on ICD 10 CA Refer any questions regarding injury coding to your provider association or access the website at www hcaiinfo ca under Auto Insurance Resources gt Statutory Accident Benefits gt Codes and Appendices 15 Providers Provider Type List v Providers Reguiated Unreguiated College Registration AISI Number If t y cm oe Last Name Firet Name Number applicable or blank SS a NNNM ES m 5o zl 1 E zl 88 8 2 J 5 12 meno quu Provider details are not required F they are the same as those on an approved plan Refer to the User Manual at wanw hcallnfo ca for coding Providers must be entered if i no plan has been submitted or ii the plan has not been approved or iii there has been a change in the providers since the plan was approved Health providers Social Workers are assigned an upper case alphabetic letter i e the Provider Reference The Provider Reference letters are used to cross reference information on previously approved plans and the Automobile Insurance Standard Invoice Assign a Provider Type code for each of the health professionals rendering services or prescribing goods Refer to Appendix E for a complete list of Provider Type codes If you are a regulated health professional or social worker provide your college registra
22. lse or misleading statement or representation to an insurer under a contract of insurance further understand that it is an offence under the federal Criminal Code for anyone by deceit falsehood 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 and costs of goods and services that are provided to automobile accident victims by health care providers preventing fraud and detecting fraud where there are reasonable grounds to suspect fraud Name of Heath Professional Social Worker or Authorized Signatory Signalure of Halin Professional Social Worker or Authorized please pet Signatory Belinda Berrington Full mailing address and other contact information must be completed AISI Facility Number AISI Facility Numbers are required for facilities and unregulated professionals but not regulated health professionals You can obtain an AISI Facility Number by registering at www hcaiinfo ca If you already have an AISI Facility Number you do not need to register again for the new invoice Regulated Health Professionals may also register for an AISI Facility Number although it is not mandatory Enter your AISI Facility Number in this field e g T If you are a regulated health professional and have not registered leave the field blank NB Future implementation of the HCAI system may eliminate the need for an
23. lth provider and goods and services information Providers have the option of using either Version A or B if an OCF 18 Treatment Plan OCF 11 DAC Assessment Plan or OCF 22 Application for Approval of an Assessment or Examination has been approved Injury and Sequelae Information OCF 21 Version B page 2 Version B pages 2 and 3 are used together for billing goods and services that have not been previously approved by the Insurer through an OCF 16 or OCF 22 They may be used at the discretion of the provider for billing any goods or services except Pre approved Frameworks use Version C pages 2 and 3 Injuries and Sequelae Sprain and strain of lumbar spine 335 Injury detalls are not required if they are the same as those on a previously approved pian Refer to the User Manual at wyg Injuries must be entered if i no plan has been submitted ii the plan has not been approved or iii there has been a change in the injuries sequelae since the plan was approved Provide a brief description of the injury and the corresponding injury code ICD 10 CA code Up to six injuries sequelae may be entered including the description and a valid ICD 10 CA code List the most significant injury first describe the patient s most significant condition that is directly related to the automobile accident and that requires health care services In a case where multiple injuries may be classified as the most significant l
24. m of all amounts in this section Make cheque payable to Family Care Clinic Other Information Make cheque payable to Enter the name of the facility clinic or person to whom the cheque should be made payable Other Information This space may be used to communicate any additional information that will help the insurer process the invoice For Insurer Use For insurer s use only Reviewed By AppowedBy S Payee Name Payment Amount This table is provided for insurers review approval and payment processes and to assist with communication with accounting functions The grand total is broken down to allow sub ledgering of interest separately from medical payments 30
25. n Version A If you wish you can choose to use Version B for goods and services that the insurer has already approved following submission of one of the forms named above Injury and Sequelae Information OCF 21 Version A page 2 This form may be used for diling goods and services that have been previously approved by the insurer through an OCF 18 or OCF 22 This form may nct be used for Pre approved Frameworks use Version C pages 2 and 3 or goods and services that nave not been previously approved use Version 5 pages 2 and 3 Injuries and Sequelae Sprain and strain of lumbar spine 335 Injury detalls are not required if they are the same as those on a previously approved pian Refer to the User Manual at wyo Injuries need only be entered if there has been a change in the injuries sequelae and no change to the planned goods and services since the plan was approved Provide a brief description of the injury and the corresponding injury code ICD 10 CA code Up to six injuries sequelae may be entered including the description and a valid ICD 10 CA code List the most significant injury first describe the patient s most significant condition that is directly related to the automobile accident and that requires health care services In a case where multiple injuries may be classified as the most significant list the injury requiring the most services Refer to Appendix A for further information on ICD 10 CA
26. n this invoice It provides details on Overdue Amounts which are the basis for Interest charges Enter Prior Balance the Auto Insurer Total from your last invoice and subtract Payments Received since your last invoice to calculate Overdue Amount 12 Totals Sub Total 217 50 Other Insurer 1 2 100 00 GST if applicable PST if applicable Auto Insurer Total 122 91 In the Totals section Sub Total is the sum of the cost of all goods and services included on all pages of this invoice MOH is the sum of all Ministry of Health and Long Term Care amounts This amount is taken from the Other Insurance amounts table column 1 MOH 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 Other Insurer 1 2 is the sum of all amounts received or payable to you from other insurers This amount is taken from the Other Insurance amounts table column 2 column 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 GST is the total GST for all goods and services included in this invoice Goods and services to which GST appl
27. ng Attribute Codes For Goods Administration and other codes GAP not included in the CCI code set enter a valid GAP code Refer to Appendix C for a list of valid GAP codes Refer any questions regarding goods and service coding to your provider association or access the website at www hcaiinfo ca under Auto Insurance Resources gt Statutory Accident Benefits gt Codes and Appendices Provider Reference Enter the Provider Reference code of the professional rendering the service or prescribing the good When a service is provided by more than one health care professional or social worker enter all Provider Reference codes separated by commas and add the appropriate Attribute Code e g IM individual with more than one provider 17 Unit Quantity and Measure Enter a number and the unit of measure to indicate the quantity of goods or services rendered on a single date of service For time based services the unit of measure is an hour Any portion of an hour is entered as a decimal e g 15 minutes is represented as 25 Hr For procedure based services the unit of measure is a procedure and is always a whole number e g a chiropractic manipulation is represented as 1 Pr Refer to Appendix F for valid Unit Measure Codes and a Conversion Table to convert minutes to hours GST and PST The only valid entry in the GST and PST columns is blank does not apply or a check mark 3 applies Amounts ass
28. ociated with GST and PST are indicated as totals and are not required at the detail level Cost Enter the cost of the good or service for the specified date Sub Total Enter the sum of all costs on this page If more pages are required duplicate page 2 only and indicate the sub total at the bottom of each page Other Insurance Information OCF 21 Version B page 3 Version B pages 2 aid 3are ised together br billig goods aid serubes tiatkaue rot bee preulotshrapproued bythe Insurer tiro igi ab OCF 18 OC F 11 or OC F 22 They may be ised atthe discretion ofthe prouker sor billig arygoods ors erukes exceptPre approued Frameworks ase wersi C pages 2 add OTHERIHSURAHCE have made reasonable enquiries of the claimant and have determined that L1 HO There is no other insurance coverage Y YES There is other insurance coverage that is potentially available idenbfied for these goods and services to coverpartially cover these goods and services MOH Is there Ministry of Health and Long Term Care MOH coverage for goods and services included in this invoice O Yes O No Y Not applicable Otter Insurer Name Other hera Plas Or Polio Namber Other XYZ Life Insurance Company HSA 87651 Insurer 1 Name of Plan Member Other liz trer s Ide tier Jonathan Smith 401 123 321 Otter lis trer Name Other lis traace Pli Or Poly Nimber Other eio Name of Play Member Other lis trer s Ide other Other lat traace detalis are sotrequired they a
29. ollege Registration AISI Number If Hourly Rate For Ineurar s Use T Last Name Firet Name Number applicable or blank ype EAH 2 2 Brown n jBmy am 80 0 amp B e lBrmian Betsy f a c oel Boom 1 Bb 2345 f sooj Refer to the User Manual at wwa hcalnfc ca tor coding The amounts shown in the example for the Block 1 and 2 fees and OT hourly fee are accurate from November 1 2003 until further notice For the period October 1 October 31 2003 inclusive these amounts are Block 1 fee 300 Block 2 fee 540 OT hourly rate 120 Providers must be entered Health providers are assigned an upper case alphabetic letter i e the Provider Reference The Provider Reference letters are used to cross reference information on the Automobile Insurance Standard Invoice Assign a Provider Type code for each of the health professionals rendering services or prescribing goods Refer to Appendix E for a complete list of Provider Type codes If you are a regulated health professional provide your college registration number and leave the AISI number blank If you are an unregulated provider you can obtain an AISI number by registering at www hcaiinfo ca NB Future implementation of the HCAI system may eliminate the need for an AISI number Since hourly rates are generally not applicable to Pre approved Frameworks enter
30. on Visits approved by the insurer on an OCF 24 Enter one line for each date of service using the code P W2 EV with a quantity and measure of 1 sn session Use page 2 to intemize the services rendered for each visit Date of Service Enter the date the good or service was rendered in the format year month day e g 2003 11 15 Description Enter a brief description of the good or service provided Code and Attributes For those services representing a diagnostic therapeutic or health care support intervention enter a valid CCI code and attribute if required Refer to Appendix B for a list of CCI codes and corresponding Attribute Codes For Goods Administration and other codes GAP not included in the CCI code set enter a valid GAP code Refer to Appendix C for a list of valid GAP codes Refer any questions regarding goods and service coding to your provider association or access the website at www hcaiinfo ca under Auto Insurance Resources gt Statutory Accident Benefits gt Codes and Appendices Provider Reference Enter the Provider Reference code of the professional rendering the service or prescribing the good When a service is provided by more than one health care professional enter all Provider Reference codes separated by commas 27 Quantity and Measure Enter a number and the unit of measure to indicate the quantity of goods or services rendered on a single date of service For time ba
31. or Substitute Decision Maker completes Parts 1 and 2 The remaining invoice can be completed by the health care provider social worker or by the individual responsible for the facility billing The health care provider or their authorized signatory must sign Part 4 Fee There is no fee associated with the completion of the Standard Invoice Return this form to ABC Insurance Company Auto Insurance Standard Invoice P O Box 123 Station A OC F 21 Toron Tu ON Use tis form ty accidens Metoccar on or ater November 1 1000 Attn Mary MacGregor 0876543 Return this form to Enter the name and mailing address of the Insurance Company responsible for handling the claim Claim Identifiers The Applicant must indicate the claim number if known the policy number and the date of the accident The claim number and policy number can be obtained from the insurance adjuster The policy number is also available on the Motor Vehicle Liability Insurance Card pink slip received with the policy declaration The Claim Number and Policy Number may be the same The accident date must be completed Forms will not be processed without it If a patient has overlapping injuries from more than one accident use the date of the accident that is most relevant to the injuries being treated Part 1 Applicant information Part 1 Dat OfBIr Y YY YMMDD Gender Tekplove Nimber Exe isin 19490525 mae O Fear 416 555 5555 4222 LastName
32. re the same ar those or a pre approued piat Other insurance may be available from the Ministry of Health and Long Term Care MOH or through an applicant s personal spousal or parental Extended Health Care plan to cover or partially cover some or all of the goods and services listed Indicate if the goods or services provided are covered by the MOH 18 Determine other insurance coverage that the applicant might have Space is available for two other insurers in the event that the applicant is covered by more than one policy for example if both the applicant and the applicant s partner or legal guardian have extended health benefits The auto insurer is not liable for any costs which are payable by any other insurer This information is not required on Version A as you have already provided it in the approved plan It may be left blank on Version B if you have already completed it on the approved plan and have elected to use Version B for invoicing Conflict of Interest Definition Conflict of Interest Definition A person has a conflict of interest relating to an invoice if i the person or a related person may receive a financial benefit directly or indirectly as a result of the provision by the related person or another person of the goods or services and the person who may receive the financial benefits is not the employee of the person who will provide the goods or services and does not have a contract with the pe
33. rson who will provide the goods or services or under which goods or services of that kind are provided Determine if you have a conflict of interest relating to this invoice Refer any questions to your college or association Other Insurance Amounts P MOH Insurer insurer ___Chipractes CT Physiotherapy 9 Massage Therapy g OtherServiceType J Toa oof 10000 000 Please Specify Other Service Type Other Insurance on this invoice for goods and services Enter the total amounts received or estimated to be payable to you on this invoice for goods and services from other insurance sources e g Ministry of Health and Long Term Care and Extended Health Care plans to which the applicant is eligible 19 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 Amounts may be signed or unsigned When you are indicating the amount payable or not payable from an Other Insurer e Use a negative sign to indicate the amount you have received or will receive directly from the collateral source or applicant This will allow collateral insurance payments to be subtracted from the sub total to determine the amount owed by the automobile insurer e Use a positive sign or leave unsigned to indicate the
34. sed services the unit of measure is an hour Any portion of an hour is entered as a decimal e g 15 minutes is represented as 25 Hr For procedure based services the unit of measure is a procedure and is always a whole number e g a chiropractic manipulation is represented as 1 Pr Refer to Appendix F for valid Unit Measure Codes and a Conversion Table to convert minutes to hours GST and PST The only valid entry in the GST and PST columns is blank does not apply or a check mark applies Amounts associated with GST and PST are indicated as totals and are not required at the detail line level Cost Enter the cost of the good or service for the specified date Other Goods and Services Total Enter the sum of all costs in this section Other Insurance Amounts Chiropractic Physiotherapy Massage Therapy Other Service Type Diease Specify Other Service Type Other Insurance for goods and services on this invoice Enter the total amounts received or estimated to be payable to you on this invoice for goods and services from other insurance sources e g Ministry of Health and Long Term Care and Extended Health Care plans to which the applicant is eligible 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 Amounts may be signed or unsigned W
35. tion number and leave the AISI number blank If you are an unregulated provider you can obtain an AISI number by registering at www hcaiinfo ca NB Future implementation of the HCAI system may eliminate the need for an AISI number If appropriate enter the hourly billing rate for each of the providers listed If you will not be billing for the proposed services using an hourly rate enter N A The box for Insurer Use may be used by insurers to total goods and services by Provider Type for statistical reporting 16 Goods and Services at of C E Decoription O ae Ir lm hus i oot Emi ei niue em S emi cmi omiweswse x xmwEa 6 e mice ord mdp om eer T xmi cmd cmi Wemam se se 55 mj e r le 1 xb 1 m xb 1 1 1 3 nar Marcel al www bcebric ce for coding Refer to Appendix B for additional examples of this section of the invoice Date of Service Enter the date the good or service was rendered in the format year month day e g 2003 11 15 Description Enter a brief description of the good or service provided Code and Attributes For those services representing a diagnostic therapeutic or health care support intervention enter a valid CCI code and attribute if required Refer to Appendix B for a list of CCl codes and correspondi
36. y S Payee Name Payment Amount This table is provided for insurers review approval and payment processes and to assist with communication with accounting functions The grand total is broken down to allow sub ledgering of interest separately from medical payments 22 Version C Version C must be used only when billing for services rendered through a Pre approved Framework Injury and Sequelae Information Injuries and Sequelae Description Whiplash WAD 2 rjury Getsis sre rct requirec if they are the same as those on the Pre approvec Framework Treatment Confirmation Form OCF 23 1S6 Refer to the User Manual at aww hcainfo ca for coding Injuries need only be entered if there has been a change in the injuries sequelae and no change to the planned goods and services since the Pre approved Treatment Confirmation Form OCF 23 198 was submitted Provide a brief description of the injury and the corresponding injury code ICD 10 CA code List the PAF injury first Up to six injuries sequelae may be entered including the description and a valid ICD 10 CA code Refer to Appendix A for further information on ICD 10 CA Refer any questions regarding injury coding to your provider association or access the website at www hcaiinfo ca under Auto Insurance Resources gt Statutory Accident Benefits gt Codes and Appendices 23 Health Providers Provider Type List v Providers Regulated Unregulated C

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