Instructions for the Victims' Compensation Board Gross Sexual Assault Forensic Examination Claim Form

Gross Sexual Assault Forensic Examination Claim Form (PDF)

Emergency Department Staff Instructions

Claim Form Section 1: Patient information

  1. Kit Tracking Number: Enter the tracking number from the examination kit in this space. You may attach one of the adhesive numbers from the kit.
  2. Patient Tracking Number: Use this space to enter a number which will connect this forensic kit claim form to the appropriate patient and that patient's records. Usually an account number or a medical record number would work.
  3. At this time, we are not making use of the "Lot number" for the kits.

Claim Form Section 2: Physician/Examiner's certification

  1. The description section is to give a general description of the services provided, not to list physical findings or a description of the crime. Please also complete the checklist of services, see Section 5.
  2. Contact: Provide a name and telephone number for a contact person in the ED. We would call this person with questions on Sections 1, 2, 3, & 5, not with billing questions.

Claim Form Section 5: Services/Charges. To be completed by ED staff.

  1. Check the “E.R. Physician or other professional fee” line when a physician or medical professional other than a SANE or SAFE performs either the emergency department screening examination or a forensic examination.
  2. Check “Emergency room, clinic, or office room fees” if there will be charges for the use of a facility.
  3. Sexual Assault Nurse Examiner (SANE) or Sexual Assault Forensic Examiner (SAFE)
    1. Check “SANE/SAFE services provided” if a SANE or SAFE performed the forensic examination.
    2. Check whether the SANE/SAFE charges were “included in ED fee” or “billed separately.”
  4. Check off all services provided, list and explain further testing, and name and match medications provided to the conditions treated. Comment further as necessary.

PLEASE PROVIDE PATIENT WITH VICTIMS’ COMPENSATION BROCHURE/APPLICATION CONTAINED IN KIT. A sexual assault victim who reports the assault to law enforcement is eligible to apply for reimbursement for losses or expenses, such as counseling costs (for the victim or a family member), lost wages, and medical expenses not part of the forensic examination. The hospital must continue to bill Victims’ Compensation directly for charges related to the gross sexual assault forensic examination.

Billing, Coding and Records Staff Instructions on back of Claim Form

Billing, Coding, and Records Staff Instructions

CLAIM FORM SECTION 4: Hospital/Facility - Billing, Coding, and Records staff:

  1. F.I.D. Number: This is the Federal tax number of the facility, necessary for payment.
  2. Patient Tracking Number in Section 1: Make sure that a number, such as an account or medical record number, has been entered as a Patient Tracking Number in Section 1. This number is the only patient identifier which will appear on your payment check, the only number to connect the patient, charges, and payment.
  3. Contact: Please provide the name and telephone number for a person in the billing office whom we can contact if we need additional information. When possible, we will try to avoid denying or returning claims.
  4. Itemized bills and statements with individual CPT codes:
    1. There must be an itemized bill listing each service and medication by name.
    2. A bill form providing a CPT code for each service must be submitted.
    3. Please note that UB-92 forms can be used only if they list a CPT code for each service rather than consolidations under categories, e.g. “Laboratory Chemistry.”

PLEASE REVIEW THE CLAIM FORMS FOR COMPLETION BEFORE YOU SUBMIT THEM.

PLEASE RETURN THEM TO OTHER DEPARTMENTS, IF NECESSARY, TO COMPLETE THEIR SECTIONS.

CONSOLIDATED HOSPITAL AND PHYSICIAN BILLS

  1. Single bill preference: In the vast majority of cases, we receive a single bill covering all services from a facility. In some cases, however, physicians bill separately. We urge hospitals and physicians to work together to devise a single billing process by which the facility would bill for all charges and disburse payments to other providers under whatever arrangement is satisfactory to the parties. It is difficult for the VCP to make multiple payments on the same case. Also, we may disburse the maximum $750 before receiving the second provider’s bill.
  2. Alternative: Submit all bills for a specific examination together. The VCP cannot make any additional payments after the maximum of $750 has been disbursed.