011. APPLICATIONS FOR COMPENSATION

01. Claim for Benefits. To claim benefits under the Crime Victims Compensation Act, the claimant shall file an Application for Compensation with the Crime Victim's Compensation Bureau of the Commission. Applications for Compensation shall be made using the form approved by the Commission. An Application for Compensation is deemed filed when it is received at the Commission’s office in Boise.

02. Providing Information. Before paying benefits to any claimant, the Commission shall gather sufficient information to establish that the claimant is eligible for benefits. The Commission may require the claimant to assist the Commission in obtaining that information.

03. Employment Verification. To verify information concerning a victim’s employment, the Commission may require the victim’s Employer or Employers to complete an Employment Verification form or the Commission may obtain such information from an Employer by telephone.

04. Order. After sufficient information has been gathered pursuant to Subsection 011.02 of this rule, the Commission may enter an award granting or partially granting benefits or an order denying benefits. The Commission may also enter orders necessary to further the purposes of the Act.

05. Finality of Order. An award or order issued by the Commission shall be final and conclusive as to all matters considered in the award or order; provided that within twenty (20) days from the date that such an award or order is issued, the claimant may file a request that the Crime Victim's Compensation Program reconsider the order, or the Crime Victim's Compensation Program may reconsider the matter on its own motion, and the order of the Crime Victim's Compensation Program shall be final upon issuance of the order on reconsideration; and provided further that, within forty five (45) days from the date that any order is issued by the Crime Victim's Compensation Program, a claimant may file a Request for Hearing before the Commission. The Hearing shall be held in accordance with the procedures set out in Section 012 of these rules. Requests for Hearing before the Commission and requests that the Crime Victim's Compensation Program reconsider an order is deemed filed when received at the Commission’s office in Boise.

06. Recipients of Payments for Medical Services. If, pursuant to any order of the Commission or the Crime Victims Bureau, it is determined that a claimant is entitled to payment of medical expenses as provided in Section 72-1019(2), Idaho Code, or funeral or burial expenses as provided in Section 72-1019(4), Idaho Code, payment shall be made directly to the medical provider or the provider of funeral or burial services unless the claimant has already paid the provider; if the claimant has already paid the provider, payment shall be made to the claimant.

07. Allowable Payments for Medical Services. The Commission shall pay providers the allowable payment for medical services under these rules adopted in accordance with Section 72-1026, Idaho Code.

a. Adoption of Standard. The Commission hereby adopts the Resource-Based Relative Value Scale (RBRVS), published by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services, as amended, as the standard to be used for determining the allowable payment under the Crime Victims Compensation Act for medical services provided by providers other than hospitals and ASCs. The standard for determining the allowable payment for hospitals and ASCs shall be:

i. For large hospitals: Eighty-five percent (85%) of the reasonable inpatient charge.

ii. For small hospitals: Ninety percent (90%) of the reasonable inpatient charge.

iii. For ambulatory surgery centers (ASCs) and hospital outpatient charges: Eighty percent (80%) of the reasonable charge. iv. Surgically implanted hardware shall be reimbursed at the rate of actual cost plus fifty percent (50%).

v. Paragraph 011.07.e. of this rule, does not apply to hospitals or ASCs. The Commission shall determine the allowable payment for hospital and ASC services based on all relevant evidence.

b. Conversion Factors. The following conversion factors shall be applied to the fully-implemented facility or non-facility Relative Value Unit (RVU) as determined by place of service found in the latest RBRVS, as amended, that was published before December 31 of the previous calendar year for a medical service identified by a code assigned to that service in the latest edition of the Physicians' Current Procedural Terminology (CPT), published by the American Medical Association, as amended:

MEDICAL FEE SCHEDULE

DESCRIPTION                     CODE RANGE(S)                                                                                                             CONVERSION FACTOR

Anesthesia                            00000 - 09999                                                                                                                      $60.05

Surgery - Group One             22000 - 22999                  Spine      

                                              23000 - 24999                Shoulder, Upper Arm, & Elbow

                                              25000 - 27299                  Forearm, Wrist, Hand, Pelvis & Hip

                                               27300 - 27999                Leg, Knee, & Ankle

                                                29800 - 29999                Endoscopy & Arthroscopy

                                               61000 - 61999                  Skull, Meninges & Brain

                                                 62000 - 62259                Repair, Neuroendoscopy & Shunts

                                                   63000 - 63999                      Spine & Spinal Cord                                                                $144.48

 Surgery - Group Two                 28000 - 28999                            Foot & Toes

                                                   64550 - 64999                        Nerves & Nervous System                                                       $129.00

Surgery - Group Three                3000 - 19999

                                                     20650 - 21999                   Integumentary System Musculoskeletal System                        $113.52                                                                                      Surgery - Group Four                  20000 - 20615                    Musculoskeletal System

                                                     30000 - 39999                    Respiratory & Cardiovascular

                                                      40000 - 49999                   Digestive System          

                                                       50000 - 59999                    Urinary System

                                                       60000 - 60999                      Endocrine System

                                                         62260 - 62999                    Spine & Spinal Cord

                                                         64000 - 64549                  Nerves & Nervous System

                                                        65000 - 69999                        Eye & Ear                                                                       $87.72                  

 Surgery - Group Five                        10000 - 12999                     Integumentary System

                                                           29000 - 29799                      Casts & Strapping                                                            $69.14

 

 Radiology                                                 70000 - 79999                     Radiology                                                                   $87.72

Pathology & Laboratory                             80000 - 89999                    Pathology & Laboratory                                             To Be Determined

Medicine - Group One                                 90000 - 90749                      Immunization, Injections, & Infusions

                                                                     94000 - 94999                      Pulmonary / Pulse Oximetry

                                                                     97000 - 97799                    Physical Medicine & Rehabilitation

                                                                      97800 - 98999                   Acupuncture, Osteopathy, & Chiropractic                                   $46.44

Medicine - Group Two                                    90750 - 92999                            Psychiatry & Medicine

                                                                       96040 - 96999                            Assessments & Special Procedures

                                                                        99000 - 99607                            E / M & Miscellaneous Services                                          $66.56

MEDICAL FEE SCHEDULE

DESCRIPTION                                     CODE RANGE(S)                                                                                                                                        CONVERSION FACTOR

Medicine - Group Three                        93000 - 93999 ardiography, Catheterization, & Vascular Studies  

                                                              95000 - 96020 CAllergy / Neuromuscular Procedures                                                                                        $72.24

 

c. The Conversion Factor for the Anesthesiology CPT Codes shall be multiplied by the Anesthesia Base Units assigned to that CPT Code by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services as of December 31 of the previous calendar year, plus the allowable time units reported for the procedure. Time units are computed by dividing reported time by fifteen (15) minutes. Time units will not be used for CPT Code 01996.

d. Adjustment of Conversion Factors. The conversion factors set out in this rule may be adjusted each fiscal year (FY), starting with FY 2012, as determined by the Commission.

e. Services Without a CPT Code, RVU or Conversion Factor. The allowable payment for medical services that do not have a current CPT code, a currently assigned RVU, or a conversion factor will be the reasonable charge for that service, based upon the usual and customary charge and other relevant evidence, as determined by the Commission. Where a service with a CPT Code, RVU, and conversion factor is, nonetheless, claimed to be exceptional or unusual, the Commission may, notwithstanding the conversion factor for that service set out in Subsection 011.07.b. of this rule, determine the allowable payment for that service, based on all relevant evidence.

f. Coding. The Commission will generally follow the coding guidelines published by the Centers for Medicare and Medicaid Services and by the American Medical Association, including the use of modifiers. The procedure with the largest RVU will be the primary procedure and will be listed first on the claim form. Modifiers will be reimbursed as follows:

i. Modifier 50: Additional fifty percent (50%) for bilateral procedure. ii. Modifier 51: Fifty percent (50%) of secondary procedure. This modifier will be applied to each medical or surgical procedure rendered during the same session as the primary procedure.

iii. Modifier 80: Twenty-five percent (25%) of coded procedure.

iv. Modifier 81: Fifteen percent (15%) of coded procedure. This modifier applies to MD and non-MD assistants.

08. Wage Loss Benefits. For the purpose of determining compensation benefits under Sections 72- 1019(1) and 72-1019(3), Idaho Code, “wages received at the time of the criminally injurious conduct� shall be the victim’s gross weekly wage; which shall be determined under Section 72-419(1)-(3), Idaho Code, if applicable, and if not, as follows:

a. If the Wages were fixed by the hour, and the victim worked or was scheduled to work the same number of hours each week, the weekly wage shall be the hourly rate times the number of hours that the victim worked or was scheduled to work each week, plus one-half (1/2) the hourly wage times the number of hours worked or scheduled each week in excess of forty (40) hours if the victim was paid time-and-a-half for work in excess of forty (40) hours per week.

b. If the Wages were fixed by the hour and the victim did not work the same number of hours each week, or if the victim was paid on a piecework or commission basis, the weekly wage shall be computed by averaging  the amounts that the victim was paid during his last four completed pay periods prior to the criminally injurious conduct and converting that amount to a weekly basis using a method consistent with 72-419(1)-(3); provided that, if the victim was employed for less than four (4) pay periods before the criminally injurious conduct, the average shall be computed based upon the time period that he worked.

c. If none of the above methods are applicable, the weekly wage shall be computed in a manner consistent with the above methods.

09. Treating Physician. A victim may choose his own treating physician. If, after filing an Application for Compensation, a victim changes physicians without prior approval of the Commission, or if, without prior approval of the Commission, he seeks treatment or examination by a physician to whom he was referred by his treating physician, the Commission may deny payment for such treatment or examination.

10. Overpayment. If the Commission erroneously makes payments, the Commission may reduce future payments by an amount equal to the overpayment or request a refund when overpayments are made to either the claimant or the provider.

11. Weekly Compensation Benefits If Victim Employable But Not Employed. If a victim is qualified under Section 72-1019(7)(a), Idaho Code, the following provisions apply:

a. If at the time of the injurious conduct the victim was receiving unemployment benefits and as a result of that conduct the victim becomes ineligible for those benefits, the claimant's weekly benefits under the Crime Victims Compensation Act shall be the lesser of one hundred fifty dollars ($150) or his weekly benefit amount under the Employment Security Law. b. If at the time of the criminally injurious conduct the victim was unemployed, but scheduled to begin employment on a date certain and if he was unable to work for one (1) week as a result of that conduct, weekly benefits under the Crime Victims Compensation Act shall be the lesser of one hundred fifty dollars ($150) or twothirds (2/3) of the amount that he would have earned at his scheduled employment, and those benefits shall be payable beginning on the date that his employment was scheduled to begin.

c. If prior to the criminally injurious conduct the victim was performing necessary household duties which he is disabled from performing as a result of that conduct and it is necessary to employ a person who does not reside in the victim's house to perform those duties, the victim shall receive weekly benefits under the Crime Victims Compensation Act equal to the amount paid to the person so employed, but not exceeding one hundred fifty dollars ($150) per week.

d. In other circumstances, the Commission may award an amount it deems appropriate.

12. Reimbursement for Transportation Expenses. If the claimant utilizes a private vehicle, reimbursement shall be at the mileage rate allowed by the State Board of Examiners for state employees. Reimbursement shall be provided only if services are not available in the local area and is limited to one (1) round trip per day. The claimant shall not be reimbursed for the first fifteen (15) miles of any round trip, nor for traveling any round trip of fifteen (15) miles or less. Such distance shall be calculated by the shortest practical route of travel. The mileage reimbursement amount shall be credited to the medical benefit.

13. Payment of Bills. Bills for treatment and sexual assault forensic examinations must be submitted within two (2) years from the date of treatment or the date of eligibility, whichever is later, to be compensable.