Instructions for the Victims' Compensation Board

Gross Sexual Assault Forensic Examination Claim Form

Emergency Department

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.
Victim 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.
At this time, we are not making use of the "Lot number" for the kits.

The description section is to describe the services not to list physical findings or a description of the crime. Please also complete the list of services, see Section 5 .
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.

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.
Check "Emergency room, clinic, or office room fees" if there will be charges for the use of a facility.
1. Check "SANE/SAFE services provided" if a Sexual Assault Nurse Examiner (SANE) or Sexual Assault Forensic Examiner (SAFE) performed the forensic examination. Check whether the SANE/SAFE is "State certified" or "In training."
2. Check "SANE/SAFE charges included in ED fee" only if the services of the SANE or SAFE were included in the ED or other facility charge and were not billed separately.
Check the "Examiner's fee" line only when a SANE or SAFE has performed the sexual assault examination, but only when there is a separately billed charge for the SANE/SAFE services.
Check off all other services provided and name and match medications provided to the conditions treated. Comment if necessary or helpful.

F.I.D. Number: This is the Federal tax number of the facility, necessary for payment.
Victim Tracking Number in Section 1 : Make sure that a number, such as an account or medical record number, has been entered as a Victim Tracking Number in Section 1 . This number is the only patient identifier which will appear on your payment check.
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.

There must be an itemized bill listing each service by name.
A bill form providing a CPT code for each service must be submitted.
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 those departments have not completed their sections.

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 $500 before receiving the second provider's bill.
Alternative: Submit all bills for a specific examination together. The VCP cannot make any additional payments after the maximum of $500 has been disbursed.