HCAI - Patient Management Program
Part 2
Insurance Company Information .......................................................................................... 36
Part 3
Invoice Information ............................................................................................................... 36
Part 4
Payee Information ................................................................................................................. 37
Part 5
Injury and Sequelae Information .......................................................................................... 37
Part 6
Other Health Providers ......................................................................................................... 37
Part 7
Reimbursable Goods and Services ........................................................................................ 38
Part 8
Other Insurance..................................................................................................................... 39
Summary................................................................................................................................................. 40
Comments .............................................................................................................................................. 40
OCF21- C Auto Insurance Standard Invoice ......................................................................................41
Part 1
Applicant Information ........................................................................................................... 42
Part 2
Insurance Company Information .......................................................................................... 42
Part 3
Invoice Information ............................................................................................................... 42
Part 4
Payee Information ................................................................................................................. 43
Part 5
Injury and Sequelae Information .......................................................................................... 43
Part 6
Other Health Providers ......................................................................................................... 43
Part 7
Goods and Services Rendered............................................................................................... 44
Part 8
Reimbursable Fees within the Guidelines ............................................................................. 44
Summary................................................................................................................................................. 45
Comments .............................................................................................................................................. 45
PMP HCAI Electronic Data Interchange .............................................................................................46
Main PMP HCAI Screen........................................................................................................................... 46
Preview Submission ................................................................................................................................ 46
Connect to HCAI ..................................................................................................................................... 47
Reports............................................................................................................................................48
Activity List.............................................................................................................................................. 48
Adjudication Log ..................................................................................................................................... 49
Adjudication Reports .............................................................................................................................. 49
Error Report ............................................................................................................................................ 50
Error Report for HCAI Authorization/Provider Error .............................................................................. 51
Insurer List .............................................................................................................................................. 53
OCF Patient History ................................................................................................................................ 53
OCF Status Report .................................................................................................................................. 54
Plan / Invoice Submission Log ................................................................................................................ 55
Facility Information ................................................................................................................................ 55
Automobile Insurance Activity in PMP ..............................................................................................56
Minor Injury Guideline (MIG) ................................................................................................................. 56
Tracking Sheets ....................................................................................................................................... 59
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