HCAI OCF-18 and OCF-23: What Adjudicators Look For

The HCAI System in Ontario

HCAI (Health Claims for Auto Insurance) is Ontario's electronic system for submitting auto insurance claim forms. It's mandatory for all health care providers billing auto insurers in Ontario.

Two key forms submitted through HCAI:

• OCF-18: Treatment and Assessment Plan
• OCF-23: Application for Determination of Catastrophic Impairment

This post covers what adjudicators look for when reviewing these forms — and how to complete them to maximize approval rates.

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OCF-18: Treatment and Assessment Plan

What It Is

The OCF-18 is submitted to request approval for:

• Treatment (physiotherapy, chiropractic, occupational therapy, etc.)
• Assessments (IMEs, functional capacity evaluations, etc.)

When it's required:

• For treatment plans exceeding $3,500 (minor injury guideline)
• For all non-minor injury treatment
• For assessments

What Adjudicators Look For

1. Diagnosis Consistency

What adjudicators check:

• Is the diagnosis consistent with the accident circumstances?
• Is the diagnosis consistent with the OCF-3 (Disability Certificate)?
• Is the diagnosis specific (e.g., "right rotator cuff tendinopathy") or vague (e.g., "shoulder pain")?

Red flags:

• Diagnosis doesn't match mechanism of injury
• Diagnosis changes without explanation
• Vague or non-specific diagnosis

How to improve approval:

• Use specific diagnostic terminology
• Ensure diagnosis matches the accident description
• Document objective findings that support the diagnosis

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2. Treatment Rationale

What adjudicators check:

• Is there a clear rationale for the proposed treatment?
• Is the treatment evidence-based?
• Is the treatment consistent with clinical practice guidelines?

Red flags:

• No rationale provided
• Treatment not consistent with guidelines
• Treatment duration or frequency excessive

How to improve approval:

• Provide a clear rationale (e.g., "Physiotherapy to improve range of motion and strength, consistent with clinical practice guidelines for rotator cuff tendinopathy")
• Reference guidelines if applicable
• Justify duration and frequency

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3. Treatment Goals

What adjudicators check:

• Are treatment goals specific and measurable?
• Are goals realistic and achievable?
• Are goals time-limited?

Red flags:

• Vague goals (e.g., "improve function")
• No measurable outcomes
• Goals not time-limited

How to improve approval:

• Use specific, measurable goals (e.g., "Increase shoulder flexion from 120° to 160° within 6 weeks")
• Include functional goals (e.g., "Return to work with modified duties within 8 weeks")
• Provide expected timeline

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4. Duration and Frequency

What adjudicators check:

• Is the duration and frequency consistent with the diagnosis?
• Is it consistent with guidelines?
• Is there a tapering plan?

Red flags:

• Excessive duration (e.g., 12 weeks of daily treatment)
• No tapering plan
• Duration exceeds guidelines without justification

How to improve approval:

• Follow clinical practice guidelines for duration and frequency
• Provide a tapering plan (e.g., "Weeks 1-4: 3x/week, Weeks 5-8: 2x/week, Weeks 9-12: 1x/week")
• Justify if duration exceeds guidelines

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5. Cost Reasonableness

What adjudicators check:

• Are costs consistent with the Ontario Schedule of Benefits?
• Are costs consistent with market rates?
• Are there multiple providers billing for similar services?

Red flags:

• Costs exceed Schedule of Benefits without justification
• Multiple providers billing for similar services
• Costs seem excessive for the service

How to improve approval:

• Use rates consistent with the Schedule of Benefits
• Justify any costs that exceed standard rates
• Avoid duplication of services

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6. Previous Treatment

What adjudicators check:

• Has the claimant had similar treatment before?
• What was the outcome?
• Why is more treatment needed?

Red flags:

• Multiple treatment plans for the same condition
• No improvement with previous treatment
• No justification for additional treatment

How to improve approval:

• Document previous treatment and outcomes
• Explain why additional treatment is needed (e.g., "Previous physiotherapy improved pain but did not achieve full function. Additional treatment focused on strengthening is recommended.")
• Provide measurable progress

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7. Assessment Necessity

What adjudicators check:

• Is the assessment necessary?
• Is the assessor qualified?
• Is the cost reasonable?

Red flags:

• Assessment not clearly related to the claim
• Assessor not qualified
• Cost excessive

How to improve approval:

• Provide a clear rationale for the assessment (e.g., "Functional capacity evaluation to determine ability to return to work")
• Ensure the assessor is qualified (e.g., occupational therapist with FCE certification)
• Use reasonable costs

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OCF-23: Application for Determination of Catastrophic Impairment

What It Is

The OCF-23 is submitted to request a determination that the claimant has a catastrophic impairment, which entitles them to enhanced benefits (up to $1,000,000 for medical/rehabilitation and attendant care).

When it's required:

• When the claimant believes they meet the criteria for catastrophic impairment
• Must be submitted within 2 years of the accident (or within 2 years of when the claimant knew or should have known they were catastrophic)

What Adjudicators Look For

1. Criteria Selection

What adjudicators check:

• Which catastrophic impairment criteria is being claimed?
• Is the criteria appropriate for the claimant's condition?

Catastrophic impairment criteria under SABS:

1. Paraplegia or tetraplegia
2. Severe impairment of ambulatory mobility or use of an arm
3. Severe impairment of vision
4. Severe impairment of speech
5. Severe impairment of cognitive function (brain injury)
6. Physical impairment combination (55% or more whole person impairment)
7. Mental or behavioral disorder combination (Class 4 or 5 impairment in 3 or more areas)
8. Combination of physical and mental/behavioral impairments

How to improve approval:

• Select the most appropriate criteria
• Ensure the claimant meets the specific criteria
• Provide supporting documentation

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2. Medical Evidence

What adjudicators check:

• Is there comprehensive medical evidence supporting the claim?
• Are the assessments conducted by qualified professionals?
• Are the assessments recent and relevant?

Required medical evidence:

• Comprehensive medical reports
• Specialist assessments
• Imaging and diagnostic tests
• Neuropsychological testing (for brain injury)
• AMA Guides impairment rating (for physical impairment combination)

Red flags:

• Incomplete medical evidence
• Assessments not conducted by qualified professionals
• Assessments outdated

How to improve approval:

• Provide comprehensive medical evidence
• Ensure assessments are conducted by qualified professionals
• Use recent assessments (within 6-12 months)

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3. Impairment Rating

What adjudicators check:

• Is the impairment rating calculated correctly?
• Is it based on the AMA Guides (6th edition)?
• Does it meet the threshold (55% or more for physical impairment combination)?

Red flags:

• Impairment rating not calculated correctly
• Not based on AMA Guides
• Does not meet threshold

How to improve approval:

• Ensure impairment rating is calculated by a qualified professional
• Use the AMA Guides (6th edition)
• Document the calculation clearly

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4. Functional Impact

What adjudicators check:

• How does the impairment affect the claimant's function?
• Is there evidence of severe functional limitations?

Red flags:

• Impairment rating high but functional impact low
• No evidence of functional limitations

How to improve approval:

• Document functional limitations (e.g., "Claimant requires wheelchair for mobility, needs assistance with all ADLs")
• Provide functional assessments (e.g., FCE, home assessment)
• Document need for attendant care

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5. Consistency

What adjudicators check:

• Is the catastrophic impairment claim consistent with the medical evidence?
• Is it consistent with the claimant's functional presentation?

Red flags:

• Claim inconsistent with medical evidence
• Claim inconsistent with functional presentation

How to improve approval:

• Ensure claim is supported by medical evidence
• Ensure claim is consistent with functional presentation
• Address any inconsistencies

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Common Mistakes to Avoid

OCF-18 Mistakes

1. Vague diagnosis: Use specific diagnostic terminology
2. No rationale: Provide clear rationale for treatment
3. Vague goals: Use specific, measurable goals
4. Excessive duration/frequency: Follow guidelines
5. No previous treatment documentation: Document previous treatment and outcomes

OCF-23 Mistakes

1. Wrong criteria: Select the most appropriate criteria
2. Incomplete medical evidence: Provide comprehensive evidence
3. Incorrect impairment rating: Use AMA Guides correctly
4. No functional impact: Document functional limitations
5. Inconsistent claim: Ensure claim is supported by evidence

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Key Takeaways

1. OCF-18: Provide specific diagnosis, clear rationale, measurable goals, appropriate duration/frequency, and document previous treatment.
2. OCF-23: Select appropriate criteria, provide comprehensive medical evidence, calculate impairment rating correctly, document functional impact, and ensure consistency.
3. Adjudicators look for evidence-based, reasonable, and consistent requests.
4. Avoid vague language, excessive requests, and incomplete documentation.
5. Use qualified assessors and follow clinical practice guidelines.

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What's Next?

In our next post, we'll tackle "Preparing Medical Evidence for Ontario LAT Hearings" — the fourth in our Canadian series.

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This post is part of our series on Canadian medical-legal documentation. For more, see our Ontario SABS Medical Records Guide.

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Questions for Readers:

• What challenges have you faced with OCF-18 or OCF-23 submissions?
• How do you handle denials or modifications by insurers?
• What's your experience with catastrophic impairment determinations?