“Listed expenses” are the assessments, examinations, reports, forms, plans, goods and services that need to be billed through the HCAI system using an Auto Insurance Standard Invoice (OCF-21).
The insurer can pay a licensed service provider, and a facility directly in their legal or trade name as listed on the Public Registry of Licensed Service Providers.
An insurer cannot pay an unlicensed service provider directly for listed expenses, nor can an unlicensed service provider request that an insurer payment be redirected to a licensed facility.
However, insurers can pay both licensed and unlicensed service providers directly for expenses for goods and services that are not listed expenses. As, they are not subject to either the HCAI Guideline or service provider licensing regulations.
Sections 15 & 16 of the Statutory Accidents Benefits Schedule (SABS) require an auto insurer to pay only for medical and rehabilitation expenses that are “reasonable and necessary.”
An insured person would generally be expected to visit a health care provider’s place of business for most medical or rehabilitation services.
However, in appropriate circumstances, an OCF-18 (Treatment and Assessment Plan) could seek the insurer’s prior agreement to pay for the actual provision of those services and the provider’s travel time (e.g., to and from an insured person’s home, school, workplace or other functional community setting) to provide those services. In such a case, the SABS would require the insurer to agree to and pay for only as much (if any) of the provider’s travel time as deemed “reasonable and necessary” in the circumstances. The maximum fee payable by the insurer for any “reasonable and necessary” travel time would be governed by the Professional Services Guideline.
A disagreement between an insured person and an insurer over whether any provider travel proposed in an OCF-18 is “reasonable and necessary” would be managed through the dispute resolution process, just as would be the case with a disagreement over whether any proposed medical or rehabilitation service itself is “reasonable and necessary.”
Sections 15(2)(c), 16(4)(f) and 19(1)(b) of the SABS provide that an auto insurer is liable only for transportation expenses that are “authorized transportation expenses” as defined in section 3(1).
In section 3(1), and in the Transportation Expense Guideline referenced in that section, “authorized transportation expenses” are expressly limited to expenses related to the transportation of the insured person and the insured person’s aide or attendant, if any.
As a result, any mileage and other expenses related to the transportation of anyone other than the insured person (and aide or attendant, if any) are not “authorized transportation expenses” under the SABS. Auto insurers are not required to pay for such expenses if claimed by a service provider, even in circumstances where the insurer is paying for the provider’s travel time.
Attendant care benefits
An OCF-21 can be submitted through HCAI for attendant care assessments and/or the completion of the OCF-18.
Need more help?
If you have more questions about listed expenses for service providers, please contact FSRA by email at [email protected].