Provider Information

The Crime Victims Compensation Program has established the following to simplify and expedite the processing of your claims:

• To ensure payment, all claims must be submitted on CMS 1500 or UB04 and include CPT codes.
• Treatment records must be attached for each date of service. These can be chart notes, session notes, treatment summary reports, or medical records.
• Insurance explanation of benefits and all third party payment information should be attached for each date of service. Insurance denials such as “duplicate” or “held pending receipt of a questionnaire” are not acceptable.
• An itemized billing must be submitted for each patient. Do not combine patients on the same billing.
• An Initial Treatment Plan must be completed by the service provider before payment can be made for mental health treatment, medication management, physical therapy, chiropractic, and massage therapy. Other documentation may be requested as needed in order to process your claim.
• For mental health claims, progress reports (on a form provided by the Program) must be completed and submitted to the Program every 180 days, or as requested by the Program.
• A separate Family Assistance Application must be submitted for each family member seeking counseling benefits. Only immediate family members of homicide, sexual assault, domestic violence, kidnapping, or child physical abuse victims are eligible for Family Assistance Benefits. Family members include the parents, children grandparents, grandchildren, siblings, or spouse of primary victim. An itemized billing and session notes for each date of service must be submitted. Please note the name of the primary victim on the bill for family assistance benefits.
• The Program will send an Explanation of Benefits to you with detailed information regarding the status of your claim when the claim is processed.
• Anyone seeking reimbursement from the Program must have a completed W-9 Form on file with us.
• Payment for services will be issued separately by the Office of the State Controller.  Information regarding checks can be found through the Controller’s website.
• If you have further questions, contact the claims department.