New Guidelines for Auto Insurance Health Claims

May 17, 2010, Kitchener, Ontario

Posted by: Robert Deutschmann, Personal Injury Lawyer


To the attention of all insurance companies licensed to transact
auto insurance in Ontario and all health care providers
With this Bulletin, the Financial Services Commission of Ontario (FSCO) is releasing the Health Claims for Auto Insurance 2010 Rollout Guideline – Superintendent’s Guideline No. 01/10 (Guideline).  This Guideline replaces the previous Health Claims for Auto Insurance 2009 Pilot Guideline – Superintendent’s Guideline No. 03/09 that was issued in September 2009. 
This Guideline is being issued because the operation of the Health Claims for Auto Insurance (HCAI) system in the pilot phase has demonstrated that it meets performance expectations.  It sets out the process for the re-introduction of mandatory participation for all insurance companies licensed to transact auto insurance in Ontario, and for the phased re-introduction of mandatory participation for health care facilities and their associated providers who assess and/or treat individuals involved in motor vehicle accidents in Ontario. 
An amended version of this Guideline will be issued before September 2010, to reflect the implementation of the new Statutory Accident Benefits Schedule – Effective September 1, 2010, which is associated with the government’s auto insurance reform initiative.
HCAI 2010 Rollout Guideline
This Guideline is issued pursuant to section 268.3 (1) of the Insurance Act for the purposes of setting out the requirements for delivery of certain documents under sections 44.1(1) and 68(3.2) of the Statutory Accident Benefits Schedule – Accidents on or after November 1, 1996 (SABS). The Guideline enables the transmission of certain accident benefit claims forms between health care providers and insurers by way of a Central Processing Agency (CPA).  The CPA is the agent designated to receive accident benefit claim forms on behalf of insurers.
As indicated in the Guideline, the system is designed to enable health care facilities to enrol in HCAI for the purpose of transmitting Ontario Claim Forms (OCF) 18, 21, 22 and 23 to auto insurers.  Health care facilities may submit OCF forms to HCAI in one of two ways: either electronically (via the Web or a Practice Management System interface), or in paper format. Paper submissions need to be made to HCAI’s data entry centre (DEC), where the data will be transcribed, and once validated, submitted electronically to the insurer.  The DEC becomes available as of May 22, 2010. In addition to receiving forms, the CPA will confirm that forms are completed and then make this information available to the insurers to whom they are addressed. The CPA also enables insurers to communicate claims approval and payment decisions to health care facilities.
The Guideline also:
  • States that all insurers, and those health care facilities named on FSCO’s website, are subject to the Guideline;
  • Designates Health Claims for Auto Insurance Processing (HCAI Processing), an Ontario not-for-profit corporation, as the CPA;
  • Sets out specific accident benefit claim forms that are subject to this Guideline and that must be delivered to the CPA;
  • Describes how to deliver documents to the CPA;
  • Includes rules governing attachments and when documents are considered to be received by the CPA;
  • Includes rules dealing with the deemed receipt of documents;
  • Includes coding information required to complete specified forms and documents; and
  • Provides other technical details regarding HCAI and the CPA.
HCAI Participant List
After May 22, 2010, FSCO will no longer maintain the HCAI Participant List for insurers, as the system will become mandatory for all insurers who are licensed to transact auto insurance in Ontario. 
HCAI Participating Provider List
Health care providers or facilities that wish to submit and receive information through the CPA must first enrol with the CPA, and agree to specific terms and conditions. The terms and conditions deal with confidentiality, security, liability, access and data integrity.  Appendix 1 of the Guideline provides information on how to access the HCAI Participating Provider List, which provides the names of health care providers or facilities that are subject to the Guideline, and the dates their participation begins.
The HCAI Participating Provider List will be maintained by FSCO and is expected to be updated, at a minimum, on the first Monday of each month (or the next business day in the event of a holiday). The latest list is available on FSCO’s website at:
Paper Submissions
HCAI’s DEC has been established in order to allow for the submission of paper forms to any insurer by a Participating Provider, as defined in the Guideline. Starting May 22, 2010, paper versions of the forms may be delivered to HCAI’s DEC – who will validate data on the forms, and then once validated, send them electronically to the insurer. Please note that a health care facility must choose which system it wants to use with HCAI, as it cannot be enrolled in both the electronic and paper submission systems simultaneously.
As indicated in the Guideline, any attachments to a form must be delivered directly to the insurer, and not sent to HCAI’s DEC. Any attachments that are sent to the DEC will be considered not received by the insurer, and will be destroyed, not returned.
Any documents that are submitted to HCAI’s DEC must be properly completed in accordance with the directions set out in the OCF forms, and the validation rules that are attached to the Guideline. HCAI’s DEC will notify health care facilities of forms that are incomplete, or incorrectly completed, within two business days of receipt. Health care facilities are encouraged to correct any errors that are identified by the DEC in its error report, and to resubmit the form as quickly as possible.
Enrolment in HCAI
Insurers and health care facilities must complete the enrolment process for HCAI before using the system.  Any forms that are delivered to HCAI prior to enrolment will not be processed.
Please note that there are separate enrolment processes for each mode of transmission (electronic or paper). Facilities must notify HCAI if they wish to switch from one mode to another, and must complete the appropriate enrolment process.
Effective Date
The Guideline applies to all insurers that issue auto insurance policies in Ontario, and to participating health providers and facilities in respect to documents specified in the Guideline that are delivered on or after May 22, 2010 – regardless of the date of the accident to which they relate.
The Guideline will be published in an upcoming edition of The Ontario Gazette.
Additional HCAI Information
Inquiries, questions and additional information on the HCAI system (e.g., enrolment, coding, technical specifications, and educational material) can be found online at:  If a question is not addressed by this website, please contact HCAI Processing by telephone or e-mail:
Philip Howell
Chief Executive Officer and
Superintendent of Financial Services
May 12, 2010
Posted under Accident Benefit News, Automobile Accident Benefits, Car Accidents, Catastrophic Injury

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