OCF-18 Treatment Plan - Web User Manual
Contents
1. 7 PART 7 PRIOR AND CONCURRENT CONDITION 7 PART 8 ACTIVITY LIMITATIONS 8 TAB PART 9 GOALS OUTCOME EVALUATION METHODS AND BARRIERS TO RECOVERY 9 PART 10 SIGNATURE OF APPLICANT cccescecescscescscnscscnscscnccscncescncnscncnsesenscsenscsenecscnensesenssensesenenses 9 A So re 10 PART 12 PROPOSED GOODS OR SERVICES REQUIRING INSURER APPROVAL 10 E R A 12 aN E SE EE EE AAN A 13 EXPLANATION OF GOOD amp 13 TAB acecudenedesetanedeuuseancesesecsceeeseaudeendeaudewnteouseecsecusesedeausescdecesesciacesesuteaneeeadeustevesesuteendeswse 14 ADDITIONAL COMMENTS amp 14 SIGNATURE S ON OCF 18 PRINTING THE COMPLETED OCF2. TAB 4 Part 9 Goals Outcome Evaluation Methods and Barriers to Recovery Figure 10 Goals outcome measures and barriers to recovery Part 9 Plan Goals Outcome Evaluation Wethoeds and Barriers to Recowery Goals Identify the regard to the applicants impairment s gt ymptom s or pathology that this Treatment and Assessment Plan seeks to achiewe H pain reduction Increadh strengin increased range _hotion ofmer s E Select from the functional goals that this Treatment ard Assessment Flan seeks to achiewe reum to acmis of nomal Iking return to med work return to pre acck B Evaluation 1 How will progress on the goals in A t and Afi be evaluated visual analogue scale for pain Baseline is 7 out of 10 Strength measured by manual muscle testing Currently knee expension is 4 5 Currently able to climb steps independently and sequentially i f this i subsequent Treatment and Assessment Plan what was the applicants improvement at the end of the prewious plan based on your evaluation methai WAS 9 10 down to 7710 was 3 5 Stairs new do steps Prewiously could only do 3 steps Barriers to recovery 1 Have you identified any other barriers to recoweny Yes Please ib Do you have any recommendations andlor strategies to overcome these barriers O Yes pime explain D Concurrent Treatment 1 Are you aware if any co
3. WOO Health Claims for Auto Insurance OCF 18 TREATMENT amp ASSESSMENT PLAN Manual for Web Users July 2015 TABL OF CONTENTS CREATE AN 18 IN Oa ov CLAM ID NI IER a 3 PLAN aa dere ai aaa eaa 3 PART 1 APPLICANT INFORMATION 3 PART 2 AUTO INSURER INFORMATION cccccscecececececececececececucucucucucncnenenenenenenenensnenseeeeeeeeeeesaseseeaeaes 3 PART 3 OTHER INSURER INFORMATION 4 UPS 2 occa caivecie cei suse wanes E EE eset eure PART 4 SIGNATURE OF HEALTH PRACTITIONER ssscscescscescecnccscncescncescncescncnsenenseneneeseuseseneeseneesanenss 5 PART 5 SIGNATURE OF REGULATED HEALTH 6 PART 6 INJURY AND SEQUELAE
4. Phone 416 555 5555 Fax 416 111 1111 E mail mtubis ibc ca 15 the signature on THE HEALTH PROFESSIONAL OR SOCIAL WORKER CONFIRMS THAT THE INFORMATION PROVIDED 15 TRUE AND CORRECT THE HEALTH PROFESSIONAL OR SOCIAL WORKER UNDERSTANDS THAT IT 15 AN OFFENCE UNDER THE INSURANCE ACT to knowingly make a false or misleading statement or representation to an insurer under contract of insurance THE HEALTH PROFESSIONAL OR SOCIAL WORKER FURTHER UNDERSTANDS THAT IT 15 AN OFFENCE UNDER THE FEDERAL CRIMINAL CODE for anyone by deceit falzehood or other dishonest act to defraud or attempt to defraud an insurance company Ove Select the name of the regulated Health Professional who will supervise the Plan Select Yes or No in response to the question Is the signature on file Insert the date on which the signature of the regulated Health Professional is obtained TAB 3 Part 6 Injury and Sequelae Information List the injuries and sequelae that are a direct result of the automobile accident Descriptions will be provided with the corresponding injury code ICD 10 CA Each code should be listed only once regardless of how many Health Care Providers will be engaged in the treatment first line item should reflect the primary reason you are proposing services with the most significant injury first In a case where multiple injuries may be classified as the most significant li
5. direct OCFs appropriately you should determine typically by asking the Applicant Patient or the independent Adjuster the name of the licensed Insurer that insures the Applicant Patient Policy Holder Details If the injured person seeking treatment is the Policy Holder select Yes to the question Is the Policy Holder the same as the Applicant the injured person is not the Policy Holder select No and enter the last name of the Policy Holder The name of the Policy Holder can be obtained from the pink slip of the proof of insurance form Part 3 Other Insurer Information The Patient guardian or substitute decision maker can advise whether the Patient has other insurance The auto insurance system requires other insurance plans to be accessed before auto insurance health benefits are accessed Health benefits may be available from the Ministry of Health and Long Term Care MOH or through an applicant s personal spousal or parental extended health plan to pay or partially pay expenses listed in the form Space is available for up to two other Insurers in the event that the Applicant is covered by more than policy for example both the Applicant and the Applicant s partner or legal guardian have extended health benefits TAB 2 Part 4 Signature of Health Practitioner Name of Provider Using the drop down menu select the Health Practitioner from your Facility s Provider list sel
6. al CANCEL FRINT identifier Please provide th OCF 18 Nur i Date 2012 0810 Source Web OCF Effectwe Date 2010 05 01 Archival Status Not Arched 1 Enter Claim Number and or Policy Number Applicant must provide the Claim Number if Known the Policy Number and the date of the accident Claim Number and Policy Number be obtained from the insurance Adjuster Policy Number is also available on the Motor Vehicle Liability Insurance Card pink slip Claim Number and Policy Number may be the same 2 Enter the accident date If the Applicant Patient has overlapping injuries from more than one accident use the date of the accident that is most relevant to the injuries being treated Plan Identifier This information will be populated when the Plan is submitted No action is required Part 1 Applicant Information Applicant or substitute decision maker should provide this information to the Facility Date of birth of the Applicant Patient Gender of the Applicant Patient Part 2 Auto Insurer Information Applicant or substitute decision maker should provide this information to the Facility Independent adjusting companies and Adjusters Independent adjusting companies may be hired by Insurers to adjudicate Claims but the application does not list independent adjusting companies
7. d reflect the cost to deliver that service by the Provider listed for 0 5 HR Note Do not insert the hourly rate in this column 15 minutes of massage 0 25 HR by a massage therapist 25 of the RMT s hourly fee e g 0 25 x 53 66 13 41 This amount should be entered in the field under the Cost column Total count Enter the total number of times the service will be delivered during the course of the Treatment Plan o Examples Treatment to be delivered twice per week for 6 weeks 12 treatment visits If the exercise will be delivered during each visit then Total Count 12 lf the assessment will only take place once during 6 weeks then Total Count 1 Total cost This amount is calculated by multiplying the Cost per line item by the Total Count per line item o Example lf 0 25 HR of chiropractor time 26 00 and Total Count is 12 will calculate 26 x 12 312 Proposed Tax If Tax is applicable to a line item check the box One Provider and multiple line items There is a shortcut to inserting one Provider name in multiple line items I Complete all fields except for the Provider Reference fields ll Tick each box to the left of each completed line item lil Click on the button Select the name of the Provider from the dropdown list Figure 13 Apply one provider to several lines of goods and services GS Code Attr Provider Reference Quantity Mea
8. dentified in Part 6 No Yes Please explain O Unknown B Since the accident has the applicant developed any other disease condition or injury not related to the automobile accident that could affect hisiher response to treatment for the injuries identified in Part 67 No Yes Please explain Unknown This part of the OCF 18 assists the Insurer to better understand the Applicant s pre accident status It informs the Insurer of any pre existing condition s that may affect the Applicant s response to treatment provides additional information around circumstances that may affect recovery and that are not indicated as a prior or concurrent condition Note If you are aware that an Applicant will receive treatment for a concurrent condition this can be documented in Part 9 Provide relevant information to the best of your knowledge and based on information from the Applicant A response of Unknown may prompt a request for further clarification from the Insurer f additional space is required use the space under Additional Comments Tab 6 8 Activity Limitations Figure 9 Activity limitation Part amp Activity Limitations Indicate any activity limitations that the applicant is experiencing A Does the applicant s impairment s from the injuries in Part 6 affect his her ability to carry out Hisvher tasks of employment O No Yes Please e
9. e 0 00 0 00 Auto Insurer Total 1 300 00 HCAI populates the proposed and calculated tax columns with the HST rate 13 You may overwrite the Proposed Tax amount if you are charging a tax value that is different from HST CALCULATE Recalculate proposed tax to reflect HST on selected taxable items Please indicate any additional comments regarding proposed goods and services Your message be to 500 characters length Additional comments may be entered here 13 TAB 6 Additional Comments amp Attachments Additional Comments Please note that the document is not considered complete until the attachments if any are indicated recened by the insurer is mandatory to indicate the number and of documents reports that are being sent Attachments being sent if any Family physician report 5 enables Facilities to do the following o Offer more information to Adjusters by using the space provided in Tab 5 o Advise Adjusters that additional documentation attachments is being sent which the Insurer requires to adjudicate the form How should attachments be sent Attachments must be faxed mailed directly to the Adjuster o Attachments cannot be sent electronically via HCAI and should not be sent to HCAI To indicate that an attachment is being sent to the Adjuster check off Attachments being sent if If this box is ticked the Facility must use the spac
10. e below to describe the attachment being sent Signature s on OCF 18 Printing the completed OCF Signatures are not transmitted to the Insurer however hard copies of the form must be printed and signed and kept on file at the Facility obtain signatures the entire OCF should be completed To print a form o on the button located at the top and bottom of the OCF page Figure 20 Print button Create OCF18 HCA l 4 gt 4 4 F s Yg 4 BACK NEXT 1 User Manual CANCEL PRINT SAVE Claim Identifier Plan Identifier Applicant Name a Document Number Claim Number 54123 s OCF 18 Policy Number 123413 Date 2012 08 16 Date of Accident 2012 08 01 MiM 1 1 Source Web OCF Effective Date 2010 09 01 Archival Status Not Archived 14
11. ect Other if the Health Practitioner is external and not in your Provider list the Health Practitioner s detailed information Part 4 Signature of Health Practitioner PHame Proven Physio Peter Address 1 1 Address Street Is this injury subject to a PAF or Minor Injury Guideline f accident occurred before September 1 2010 answer Yes or No to the question Is this an impairment referred to in a PAF Guideline Beginning February 1 2014 FSCO has changed the language for accidents that occur on or after September 1 2010 but the language in HCAI will not be updated except on the PDF printout Although the question asks whether not the impairment is predominantly a minor injury as referred to in the Minor Injury Guideline effective February 1 2014 the OCF 18 requests the Health Practitioner explain and provide compelling evidence why the applicant does not come within the Minor Injury Guideline due to a pre existing medical condition that was documented by me or another Health Practitioner before the accident Explanation for submitting an OCF 18 When Yes is selected to the above questions an explanation should be provided in the text box You may indicate that you will be sending attachments as documented evidence for the pre existing condition o This is done in Tab 6 of the Additional Comments section by check marking the box Attachments b
12. eing sent if any Attachments are sent directly to the Insurer not to HCAI Is the signature on file Answer Yes or No OCF 18 cannot be submitted unless the answer to this question is Yes Use the calendar or insert the date of signature the field beside Signed Date Is the Health Practitioner certifying the plan also the Regulated Health Professional who is preparing and supervising the plan Select Yes if the Health Practitioner is in your Providers list and is going to supervise the Treatment Plan Signature in Part 5 not required Select if the Health Practitioner is in your Provider List but is not going to supervise the Treatment Plan Signature in Part 5 is required Select No if the Health Practitioner is external Signature in Part 5 must be completed Part 5 Signature of Regulated Health Professional Figure 6 Signature of regulated Health Professional Part 5 Signature of Regulated Health Professional Please indicate that there is provider signature on file Values marked with an asterisk are mandatory fekis required for submission Name of Provider Profession Facility Name Ontano Physio Facility Registry Number 100631 FSCO Facility Licence Number 100631 Service Address Address 1 200 Main St Address 2 City Toronto Province Ontario Postal Code 1 1M1
13. exam Code Note The OCF 18 does not allow MIG PAF codes Enter the intervention by typing it directly into the field under Code or use the code search utility by clicking the blue ellipses B next to the code field Figure 12 Intervention code Code 1 09 B Stimulation 1 Select either Canadian Classification of Interventions GAP codes be used for services that are not well reflected in the CCI Refer to Appendix available at www hcaiinfo ca or contact your Health Professional Association Attribute These codes are used to indicate how the service was delivered or for example the number of views in an X ray study Attribute is not mandatory can be left blank Provider reference Use the dropdown list to select the Health Care Provider who delivered care on a given date f more than one Health Care Provider delivered care list only the one who was most responsible for each visit that is listed on the Invoice Quantity and unit measure Enter the quantity and unit measure of service that will be provided during a single treatment visit session o Examples 15 minutes 0 25 HR 1 procedure 1 PR 1 good like a back support 1 GD 10 km 10 KM 10 1session 1SN Cost Report the cost per service as described in the line o Examples If the service is being delivered for 0 5 HR the Cost column shoul
14. ing section have been completed click CALCULATE HCAI calculates Tax HST and enters the amount into the Auto Insurer Total If you wish to manually enter a different tax amount for your invoiced goods services Click and uncheck the button underneath the Totalling box ll Enter the new amount in the Tax if applicable field Click for the new Auto Insurer Total Explanation of Good amp Services Use the space below the Totalling to provide more detail if the code doesn t offer enough details If there is not enough space in this section you may also use the Additional Comments field in Tab 6 Figure 18 Add note with more detail for Adjuster GS Code Attr Provider Reference Quantity Measure Cost Total Total Proposed Ref Count Cost Tax 1 B Morson Sally i 1 550 00 1 550 00 Med Rehab 2 40 Morson 1 PR 750 00 1 750 00 Magnetic resonan 3 B E GD 0 00 4 B GD 0 00 E 5 GD 0 00 Use these buttons with the checkboxes on the left Estimated duration of this Plan weeks How many visits have you already provided visits Has the applicant or substitute decision maker confirmed consent by initialing the proposed goods and services C No Yes Total Count Sub total Minus MOH Minus Other Insurer 1 2 0 00 Tax if applicabl
15. ncurrent treatment mot included in this Treatment and Assessment Plan will be provided by any other providerfacility Yes pka eplan The information in Part 9 should be consistent with the intervention codes provided in Part 12 Part 10 Signature of Applicant e Complete the treatment plan and review with the Applicant or substitute decision maker Answer the question Is the applicant s or substitute decision maker s signature waived by the insurer TAB 5 Part 12 Proposed Goods or Services Requiring Insurer Approval Part 12 Proposed Goods or Services Requiring Insurer Approval To the extent possible this Treatment and Assessment Plan should include all Goods amp Services contemplated by the Regulated Health ProfessionalFacility referred to in Part 5 for the period of this Treatment and Assessment Plan Please fill out all Goods and Services and associated information To create a session select the check box for each Goods amp Services to be included in this session and then click the Create Session button To delete any items from a session code select the session code in question and use the Separate Session button If HST applies to a good or service check Proposed Tax checkbox on that line item Estimate Day Projected GS Code Provider Reference Quantity Measure Cost Total Total Proposed Ret Count Cost Tax 1 2 02 Bi Smith John 050 HR 10 50 16 168 00 A Assessment
16. r substitute decision maker confirmed consent by initialing the proposed and services No Yes Totalling e Total Count is the sum of the count of all proposed goods and services which is calculated by HCAI Sub total is the sum of the cost of all proposed goods and services which is calculated by HCAI e MOH is the sum of all Ministry of Health and Long Term Care amounts that are payable to you for any of the goods and services listed above this is subtracted from the sub total e Amounts payable by another Insurer must be entered using the negative sign e Other Insurer 1 2 is the sum of all amounts payable to you from other Insurers this is also subtracted from the sub total e is the total Proposed Tax for all goods and services listed above e Auto Insurer Total is the sum of all amounts in this section Figure 17 Totalling Proposed Calculated Total Count 24 Sub total 403 00 Minus MOH Minus Other Insurer 1 2 0 00 Tax if applicable 0 00 Auto Insurer Total 408 00 t populates the proposed calculated tax columns with the HST rate 13 may overwrite the Proposed Tax amount if you are charging tax value that is different from HST CALCULATE Recalculate proposed tax to reflect HST on selected taxable items Calculate When all of the proposed goods and or services have been entered and any required fields in the Totall
17. scccccessseeeececensseeeeeeenseeeeseoeans 14 Create an OCF 18 in HCAI An OCF 18 is used for patients with injuries that are not suitable for treatment in a Pre Approved Framework or in the Minor Injury Guideline To create an OCF 18 Healthy Life Ontario ADJUSTER RESPONSE PENDING DRAFT Plan Management Submitted Filter CREATE NEW Submitted 1 of 1 The following items have been submitted Go to the Plans tab and any sub tab Select OCF 18 from the dropdown list and click A blank OCE 18 will open OCF 18 TABS The OCF 18 in HCAI is organized under six tabs Figure 2 OCF 18 Tabs Create 18 1 User Manual F se eee reen DELETE CANCEL PRINT SAVE Tab 1 Claim Identifier Plan Identifier Part 1 Applicant Patient Information Part 2 Auto Insurer Information Part 3 Other Insurer Information Tab 2 Part 4 Signature of Health Practitioner Part 5 Signature of Regulated Health Professional Tab 3 Part 6 Injury and Sequelae Information Part 7 Prior and Concurrent Condition Part 8 Activity Limitations Tab 4 Part 9 Plan Goals Outcome Evaluation Methods and Barriers to Recovery Part 10 Signature of Applicant Tab 5 Part 12 Proposed Goods or Services Requiring Insurer Approval Tab 6 Additional Comments and or Attachments Tab 1 Claim Identifier Create OCF18 HCA sr Wa 21815 7 NET h User Manu
18. st the injury requiring the most services first use of ICD 10 CA codes is intended to classify problems it is not the equivalent of communicating a diagnosis Adding additional lines for injury sequelae codes To add lines for additional injuries simply click on the button near the bottom right of the Injury and Sequelae Codes section Figure 7 Add additional injury problem code line Injury an d Sequ elae Codes Provide the associated ICD 10 CA code for injuries and sequelae listing the most significant first that the direct result of the automobile accident Description m H Tachycardia unspecified CONFIRM CODES Refer to Appendix which is the partial pick list of injury oroblem codes available at www hcaiinfo ca or contact your Health Professional Association Part 7 Prior and Concurrent Condition Figure 8 Prior and concurrent condition Part 7 Prior and Concurrent Conditions The information provided in this section will help the insurer to better understand the applicants preaccident status and informs the insurer in advance of any pre existing condition that may affect the applicant s response to the treatment Provide relevant information in response to these questions to the best of your knowledge and based on information from the applicant A Prior to the accident did the applicant have any disease condition or injury that could affect his her response to treatment for the injuries i
19. sure Cost Total Total Proposed Count Cost Tax B Smith John F 100 FPR mempr 0 00 Smith John 8 1 00 PR 750 00 0 00 Magnetic resonan 11 Calculate Costs from Rates Figure 14 Calculate Costs from Rates Ls E 4 14VA02 Smith John 8 0 25 HR 26 00 12 312 00 E 5 GD 0 00 E N Ahen mn D Use these buttons with the checkboxes on the left Apply the Default Hourly Rate When the Providers listed on your Invoice were added to your Facility in HCAI there was an option to assign a Default Hourly Rate If the rate assigned is the correct rate to apply to your Treatment Plan click manually enter or override the rate enter the amount the Cost field instead Add more Items To add lines for additional Good and Services simply select the number of items lines you would to add from the dropdown and click on the GO button Add more Items Duration Enter the anticipated duration of the Treatment Plan and indicate how many treatment visits have already been delivered for this Plan Indicate either Yes or No to the question Has the applicant or substitute decision maker confirmed consent by initialing the proposed goods and services Figure 16 Estimated duration of Treatment Plan Estimated duration of this Plan weeks How many visits have you already provided Visits the applicant o
20. xplain C Unknown Not Employed His her activities of normal life Yes Please explain Unknown lf Yes to either of the questions above briefly describe the activities limited by the impairment and their impacts on the applicant s ability to function Your message may be up to 500 characters in length Job requires standing 3 consecutive hours per day Claimant can only stand for 1 hour at time Claimant can manage self care however it is very tiring due to pain Tries to sit during ADL where possible the applicant is unable to carry out pre accident employment activity is the employer able to provide suitable modified employment to the applicant 9 Please explain Yes Unknown Not Employed Employer has not returned call Please advise if Insurer has information regarding employment This part helps Insurers to understand activity limitations related to pre accident work and activities daily living ADLs responses are based on current knowledge of the Health Care Provider and information provided by the Applicant If any responses to the questions in section a are Yes provide a brief description of the activity limitations the Applicant is experiencing response of No in section requires further explanation and may require contacting the employer but is not intended to signify the need for a job site assessment
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