(1) The crime victims compensation program provides payment for mental health treatment and services to victims of crime who are eligible for compensation under chapter 7.68 RCW, the Crime Victims' Act.

(2) Services and treatment are limited to procedures that are:

(a) Proper and necessary for the diagnoses of an accepted condition;

(b) Available at the least cost;

(c) Consistent with accepted standards of mental health care; and

(d) Will enable the client to reach maximum recovery.

(1) The crime victims compensation program will not authorize services and treatment:

(a) Beyond the point that the accepted condition becomes fixed and stable (i.e., maintenance care);

(b) After a client is determined to be permanently totally disabled and while receiving financial support for lost wages except if the treatment is deemed medically necessary for previously accepted condition(s);

(c) When services are not considered proper and necessary. Services that are inappropriate to the accepted condition, which present hazards in excess of the expected benefit, are controversial, obsolete, or experimental are presumed not to be proper and necessary, and shall only be authorized on an individual case basis with written authorization for the service from the department;

(d) That are not considered to be evidence-based and curative treatment; or

(e) For any therapies which focus on the recovery of repressed memory or recovery of memory which focuses on memories of physically impossible acts, highly improbable acts for which verification should be available, but is not, or unverified memories of acts occurring prior to the age of two.

(2) We will not pay for services or treatment, including medications:

(a) On rejected claims;

(b) After the date a claim is closed.

(c) After the maximum benefit has been reached.

(1) The program must authorize the following mental health services and/or treatment:

(a) Consultations beyond what are allowed in WAC 296-31-065;

(b) Inpatient hospitalization;

(c) Concurrent treatment with more than one provider;

(d) Electroconvulsive therapy;

(e) Neuropsychological evaluation (testing);

(f) Day treatment for seriously ill children under eighteen years old;

(g) Referrals for services or treatment not in our fee schedule;

(h) Teleconsultations and other telehealth services.

(2) Your request for authorization must be in writing and include:

(a) A statement of the condition(s) diagnosed;

(b) Current DSM or ICD codes;

(c) The relationship of the condition(s) diagnosed to the criminal act; and

(d) An outline of the proposed treatment program that includes its length, components, procedure codes and expected prognosis.

(1) Mental health providers must qualify as an approved provider and register with the crime victims compensation program before they are authorized to provide treatment and receive payment in accordance with these rules.

(2) The following providers who are permanently licensed in Washington are eligible to register with this program:

(a) Psychiatrists;

(b) Psychologists;

(c) Advanced registered nurse practitioners with a specialty in psychiatric and mental health nursing;

(d) Ph.D.s not licensed as psychologists and master level counselors whose degree is in a field of study related to mental health services including, but not limited to, social work, marriage and family therapy or mental health counseling.

(3) Out-of-state providers must be currently licensed, or certified within the state in which they practice. Washington requires mental health counselors to have a masters degree to treat Washington crime victim clients.

You must send us:

(1) A completed provider application and Form W-9;

(2) A legible copy of your license, certification and/or registration;

(3) Ph.D.s not licensed as psychologists and master level counselors must provide a legible copy of their degree.

The department has a duty to supervise the provisions of proper and necessary mental health care that is delivered promptly, efficiently and economically. We may deny, revoke, suspend or impose conditions on your authorization to treat crime victim claimants for reasons that include, but are not limited to:

(1) Incompetence or negligence that results in injury to a client or that exposes the client to harm.

(2) The possession, use, prescription for use, or distribution of controlled substances, legend drugs, or addictive, habituating or dependency-inducing substances except for therapeutic purposes.

(3) Limits placed on your license, certification and/or registration by any court, board or administrative agency. The limits may be temporary or permanent and may involve probation, suspension or revocation.

(4) The commission of any act involving moral turpitude, dishonesty, or corruption that relates to the practice of your profession. The act does not need to be a crime. If a court or other tribunal issues a conviction or finding regarding the act, a certified copy of the conviction or finding is conclusive evidence of the violation.

(5) Failure to comply with our rules, orders or policies.

(6) Failure, neglect or refusal to:

(a) Provide us with copies of your license, certification and/or registration and degree;

(b) Provide records requested by the department pursuant to a health care service review or an audit;

(c) Provide us with complete and timely reports that we require, or additional reports or records that we request.

(7) The submission or collusion in the submission of false or misleading reports or bills to any government agency.

(8) Billing a claimant for:

(a) Treatment of a condition for which the department has accepted responsibility; or

(b) The difference between the amount paid by the department and/or public or private insurance under the maximum allowable fee set forth in these rules and any other charge.

(9) Repeated failure to notify the department immediately and prior to burial in any death, where cause of death is not definitely known and possibly related to a crime victim injury.

(10) Repeated failure to recognize emotional and social factors that impede a client's recovery.

(11) Repeated unreasonable refusal to comply with the recommendations of a board certified or qualified specialist who examines or reviews a claim for us.

(12) Repeated use of treatment that is:

(a) Controversial or experimental;

(b) Contraindicated or hazardous;

(c) Performed after the condition stabilizes; or

(d) Performed after maximum mental health improvement is reached.

(13) Mental incompetence declared by a court or other tribunal.

(14) Failure to comply with the applicable code of professional conduct or ethics.

(15) Failure to inform us of disciplinary action against your license, certification or registration to practice, issued by order or formal letter.

(16) The finding of reason(s) to take action against your privileges to practice by any peer group review body.

(17) Misrepresentation or omission of any material information in your application for authorization to treat crime victims.

(18) Repeated billing of the department for services that are available to clients from public or private insurance sources. You must bill us only after all public or private insurance benefits are exhausted.

(1) If the department finds reason to take corrective action, we may also order one or more of the following:

(a) Recoup our payments to you with interest.

(b) Deny or reduce payment.

(c) Assessment of penalties for each action that falls within the scope of WAC 296-31-045 (1) through (18).

(d) Place you on a prepayment review status that requires you to submit supporting documents prior to payment.

(e) Require you to satisfactorily complete education courses and/or programs.

(f) Impose other appropriate restrictions or conditions, including revoking your privilege to be reimbursed for treating clients under the Crime Victims Act.

(2) Cases involving questions of ethics or quality of care will be referred to the department of health.

(3) We will forward a copy of any corrective action taken against you to the applicable disciplinary authority.

(1) When you receive a payment to which you are not entitled, you must repay the excess payment, plus accrued interest, without regard to whether the excess payment occurred due to your error or department error or oversight.

(2) Interest will accrue on excess payments at the rate of one percent per month or portion of a month beginning on the thirty-first day after payment was made. When partial payment of an excess payment is made, interest accrues on the remaining balance.

(3) The department has the option of requesting you to remit the amount of the excess payment and accrued interest or offsetting excess payments and accrued interest against future payments due to you.

If you or the client do not agree with our order, decision or award a written protest may be sent to the crime victims compensation program or appeal to the board of industrial insurance appeals. A protest or appeal to our order or decision requiring repayment by a provider must be received within twenty days from receipt of the order or decision. A protest or appeal regarding other issues must be received within ninety days of receipt of the order or decision.

The crime victims compensation program requires the following reports from mental health providers:

(1) Initial response and assessment: Form I: This report is required if you are seeing the client for six sessions or less, and must contain:

(a) The client's initial description of the criminal act for which they have filed a crime victims compensation claim;

(b) The client's presenting symptoms/issues by your observations and the client's report;

(c) If the claimant is unable to work as a result of the crime injury, provide an estimate of when the claimant will return to work and why they are unable to work; and

(d) What type of intervention(s) you provided.

(2) Initial response and assessment: Form II: This report is required if more than six sessions are anticipated. Form II must be submitted no later than the sixth session, and must contain:

(a) The client's initial description of the criminal act for which they have filed a crime victims compensation claim;

(b) A summary of the essential features of the client's symptoms related to the criminal act, beliefs/attributions, vulnerabilities, defenses and/or resources that lead to your clinical impression (refer to current DSM and crime victims compensation program guidelines);

(c) Any preexisting or coexisting emotional/behavioral or health conditions relevant to the crime impact if present, and how they may have been exacerbated by the crime victimization;

(d) Specific diagnoses with current DSM or ICD code(s), including axes 1 through 5, and the highest GAF in the past year;

(e) Treatment plan based on diagnoses and related symptoms, to include:

(i) Specific treatment goals you and the client have set;

(ii) Treatment strategies to achieve the goals;

(iii) How you will measure progress toward the goals; and

(iv) Any auxiliary care that will be incorporated.

(f) A description of your assessment of the client's treatment prognosis, as well as any extenuating circumstances and/or barriers that might affect treatment progress; and

(g) If the claimant is unable to work as a result of the crime injury, provide an estimate of when the claimant will return to work and why they are unable to work.

(3) Progress note: Form III: This report must be completed after session fifteen has been conducted, and must contain:

(a) Whether there has been substantial progress towards recovery for the crime related condition(s);

(b) If you expect treatment will be completed within thirty visits (for adults) or forty visits (for children); and

(c) What complicating or confounding issues are hindering recovery.

(4) Treatment report: Form IV: This report must be completed for authorization for treatment beyond thirty sessions for adults or forty sessions for children, and again for authorization if treatment will go beyond fifty sessions for adults or sixty sessions for children. Form IV must contain:

(a) The diagnoses at treatment onset with current DSM or ICD code(s), including axes 1 through 5, and the highest GAF in the past year;

(b) The current diagnoses, if different now, with current DSM or ICD code(s), including axes 1 through 5, and the highest GAF in the past year; and

(c) Proposed plan for treatment and number of sessions requested, and an explanation of:

(i) Substantial progress toward treatment goals;

(ii) Partial progress toward treatment goals; or

(iii) Little or no progress toward treatment goals.

(5) Termination report: Form V: If you discontinue treatment of a client for any reason, a termination report should be completed within sixty days of the client's last visit, and must contain:

(a) Date of last session;

(b) Diagnosis at the time client stopped treatment;

(c) Reason for termination (e.g., goals achieved, client terminated treatment, client relocated, referred to other services, etc.); and

(d) At this point in time do you believe there is any permanent loss in functioning as a result of the crime injury? If yes, describe symptoms based on diagnostic criteria for a DSM diagnosis.

(6) Reopening application:This application is required to reopen a claim that has been closed more than ninety days, to demonstrate a worsening of the client's condition and a need for treatment. If the claimant has met or exceeded the maximum benefit, we will be unable to pay for reopening exams or diagnostic tests. If the benefits paid on this claim are less than the maximum benefit, we will reimburse you for filing the application, for an office visit, and diagnostic studies needed to complete the application up to the maximum benefit. No other benefits will be paid until a decision is made on the reopening. If the claim is reopened, we will pay benefits for a maximum of sixty days prior to the date we received the reopening application.

(1) There may be instances when the department or the claimant's mental health provider may want to refer the claimant for a consultation. For example, if the claimant's accepted mental health condition presents a diagnostic or therapeutic challenge, or if the department needs additional information to make a decision on the claim.

(2) There are two levels of consultations that can be performed: Limited and extensive. Descriptions and procedure codes are included in the Crime Victims Compensation Program Mental Health Fee Schedule and Billing Guidelines.

(3) The consultant will be required to submit a report to the department that contains the following elements:

(a) The reason(s) for the consultation referral;

(b) Consultants related recommendations;

(c) Other information as requested by the department.

(4) Authorization from the department is required for:

(a) More than two consultations before the thirtieth session for adults or fortieth session for children; and

(b) More than one consultation between thirty and fifty sessions for adults or between forty and sixty sessions for children.

(5) You may not make a referral for a consultation if:

(a) An independent medical examination has been scheduled;

(b) A consultation has been scheduled by the department;

(c) Claim reopening is pending; or

(d) The claim is closed.

(1) In some cases, treatment by more than one provider may be allowed by the crime victims compensation program. We may authorize concurrent treatment on an individual basis:

(a) If the accepted condition requires specialty or multidisciplinary care.

(b) If we receive and approve your written request that contains:

(i) The name, address, discipline, and specialty of each provider requested to assist in treating the client;

(ii) An outline of each provider's responsibility in the case; and

(iii) An estimated length for the period of concurrent treatment.

(2) If we approve concurrent treatment, we will recognize one primary attending mental health treatment provider. That provider will be responsible for:

(a) Directing the overall treatment program for the client;

(b) Providing us with copies of all reports received from involved providers; and

(c) In wage loss cases, providing us with adequate evidence certifying the claimant's inability to work.

(1) RCW 7.68.095 provides that claimants are entitled to a free choice of attending providers, who are registered with the department, subject to the limits of RCW 7.68.130 and the requirements of the claimant's public or private insurance. The provider must meet registration requirements of WAC 296-31-030.

(2) The department must be notified if a claimant changes providers.

(3) We may require a claimant to select another provider for treatment under the following conditions:

(a) When a provider, qualified and available to provide treatment, is more conveniently located;

(b) When the attending provider fails to comply with our rules;

(c) Subject to the limits of RCW 7.68.130 outlined in subsection (1) of this section.

If providers request payment from us for service, they must:

(1) Maintain all patient and billing records needed to:

(a) Determine the extent of services provided to claimants or to their family members. Each record must, at a minimum:

(i) Document the level and type of service provided; and

(ii) Where applicable, indicate the name of our representative who authorized equipment or treatment.

(b) Comply with our audit of services, if an audit is authorized.

(2) Maintain records for audit purposes for at least five years from the claimant's last treatment date.

(3) Provide records to us, if requested.

(1) We may review or audit patient and related billing records to ensure:

(a) Claimants are receiving proper and necessary care; and

(b) You are complying with our mental health rules, fee schedules, and policies.

A records review can become the basis of corrective action against you.

(2) We may review your records:

(a) Before, during or after delivery of services;

(b) For cause or at random;

(c) Using statistical sampling methods and projections based on sample findings; and

(d) At or away from your place(s) of business.

(3) We must provide you with ten working days written notice that our auditors intend to review your patient and related billing records at your place(s) of business.

(4) We will not remove original records from your place of business, but we may request copies of your records. If copies are requested, they must be legible and provided to us within thirty calendar days of receiving our request.

As a trustee of funds appropriated by the legislature, we have a duty to supervise the provisions of proper and necessary mental health care. We may enlist utilization review or management programs to monitor and control the delivery, use, and cost of necessary mental health care services. Examples include, but are not limited to, managed care contracting, prior authorization of services, and alternative reimbursement systems.

(1) You must immediately notify us when you are treating an unrelated condition concurrently with an accepted condition and provide us with the following information:

(a) Diagnosis and/or nature of unrelated condition;

(b) Treatment being provided; and

(c) The effect, if any, on the accepted condition.

(2) Temporary treatment of an unrelated condition may be allowed and payment for service authorized if:

(a) We approve your request for authorization prior to treatment;

(b) You give us a thorough explanation of how the unrelated condition is affecting the accepted condition;

(c) The unrelated condition is retarding recovery of the accepted condition; and

(d) We receive monthly reports from you, outlining treatment and its effect on both the unrelated and accepted conditions.

(3) We will not approve or pay for treatment of:

(a) An unrelated condition that has no influence or no longer influences the existing condition.

(b) A preexisting unrelated condition that was treated prior to acceptance of the crime victim's claim, unless it is retarding recovery of the accepted condition.

The remaining balance of a recovery, which is paid to the claimant but must be used to offset future payment of benefits.

(1) When an excess recovery exists, the department is not responsible for payment of bills.

(2) The provider must bill the department in accordance with the department’s medical aid rules and maximum fee schedules.

(3) The department will:

(a) Determine the amount payable according to the fee schedule;

(b) Credit the excess recovery with the amount payable; and

(c) Send the provider a remittance advice showing the amount due from the claimant.

(4) The claimant must pay the provider in accordance with the remittance advice.

(5) When the excess is reduced to zero the department will resume responsibility for payment of bills.

(1) Neither the department nor the claimant is required to pay for provider services which violate the mental health treatment rules, fee schedule or department policy.

(2) All fees listed are the maximum fees allowable. Providers must bill their usual and customary fee for each service. If this is less than our fee schedule rate, you must bill us at the lesser rate. The department will pay the lesser of the billed charge or the fee schedule’s maximum allowable.

The provider is prohibited from charging the claimant for any difference between the provider's charge and our allowable amount.

(3) Regardless of who completes the bill form, you are responsible for the completeness and accuracy of the description of services and of the charges billed.

(4) All bills submitted to the department must:

(a) Be itemized on forms approved by us.

For example: Physicians, psychologists, advanced registered nurse practitioners and master level mental health counselors may use our form or the current Health Insurance Claim Form (as defined by the National Uniform Claim Committee). Hospitals use the current National Uniform Billing Form (as defined by the National Uniform Billing Committee) for institution services and the current Health Insurance Claim Form (as defined by the National Uniform Claim Committee) for professional services.

(b) Refer to the crime victims compensation program mental health billing instructions for detailed billing information. Billings must be submitted in accordance with these instructions. Procedure codes and fees are available on the crime victims compensation website or by contacting the crime victims program.

(5) The following supporting documentation must be maintained and, if applicable, submitted when billing for services:

(a) Intake evaluation;

(b) Progress reports;

(c) Consultation reports;

(d) Special or diagnostic study reports;

(e) Independent assessment or closing exam reports;

(f) BR (by report) describing why a service or procedure is too unusual, variable, or complex to be assigned a value unit;

(g) The claimant’s or patient’s (if patient is other than claimant) private or public insurance information;

For example: When services provided are for survivors of homicide victims.

(6) The claim number must appear in the appropriate field on each bill form. Reports and other correspondence must have the claim number in the upper right hand corner of each page.

(7) You may rebill us if your bill is not reported on your remittance advice within sixty days. Unless the information on the original bill was incorrect, a rebill should be identical. Rebills must be submitted for services denied if a claim is closed or rejected and subsequently reopened or allowed.

(8) We will adjust charges when appropriate. We must provide you with a written explanation as to why a billing was adjusted. A written explanation is not required if the adjustment was made solely to conform to our maximum allowable fees. Any inquiries regarding adjustment of charges must be received in the required format within ninety days from the date of payment.

(1) Providers of mental health diagnostic and treatment services located outside the state of Washington:

(a) May bill us for services that we allow and are authorized by the crime victims compensation program mental health treatment rules;

(b) Must bill us according to the provisions of this chapter;

(c) Must bill their usual and customary fees; and

(d) Will be paid according to the Washington state crime victims compensation program mental health treatment rules and fees.

Exception: Hospitals located outside the state of Washington are paid according to WAC 296-30-081.

(2) Independent medical or mental health examinations must be billed and will be paid according to the examiner’s usual and customary fee.

(3) We will not reimburse a charge for service(s) allowed under any out-of-state crime victims compensation program unless it is allowed in chapters 296-30 and 296-31 WAC. When in doubt, the provider should contact us to verify coverage.