Ga. Comp. R. & Regs. R. 144-4-.08 - Forensic Medical Exams ("FMEs")

(1) FME Eligibility.

(a) The Georgia Crime Victims Compensation Program (CVCP) will reimburse licensed providers for forensic medical exams (FMEs) conducted with the purpose of collecting evidence related to an alleged sexual offense as defined in O.C.G.A. § 16-6-1(c) or O.C.G.A. § 16-6-2(c) that occurred in Georgia on or after July 1, 2011. At minimum, an FME must include:

1. An examination for physical trauma related to the sexual offense

2. A determination as to the nature and extent of the physical trauma

3. A patient interview

4. Collection and evaluation of the evidence collected; and

5. Any additional testing deemed necessary by the examiner in order to collect evidence and provide treatment.

(b) Eligible applications for payment must include the following:

1. Written acknowledgement by an authorized agency representative that the FME was conducted by a licensed physician, physician assistant, registered nurse, SANE-A (adult adolescent) or SANE-P (pediatric).

2. In cases where the victim is a minor or a developmentally-disabled adult, an FME application must also include a Law Enforcement or Division of Family and Children Services Verification Form or an investigative document indicating an allegation or disclosure of a sexual offense.

(c) CVCP will pay for FMEs performed in another state as long as the crime occurred in Georgia and the provider performing the exam and the facility meets the criteria set forth by the Program.

(d) FMEs conducted for minors in custody of the Department of Juvenile Justice at the time of the sexual assault are ineligible for reimbursement by the CVCP.

(e) FMEs conducted for crimes other than sexual offenses as defined in O.C.G.A. § 16-6-1(c) or O.C.G.A. § 16-6-2(c)(e.g., physical abuse) are ineligible for reimbursement by the CVCP.

(2) FME Billing/Payment Guidelines.

(a) The CVCP's Fee Schedule complies with the Georgia Worker's Compensation medical fee guidelines, as such the Current Procedural Terminology (CPT) Codes, are considered "reasonable expenses."

(b) The provider and/or facility must bill the CVCP usual and customary charges for the FME and the actual amount paid will be determined by the description in the itemized statement in conjunction with the associated CPT Code, and/or the Revenue Code, as applicable.

(c) A Registered Nurse, SANE-A (adult adolescent) or SANE-P (pediatric) must bill their usual and customary charge for the FME, and the bill for service must include a descriptive itemized statement of the service(s) provided. As a convenience, the CVCP provides a CPT Code/Description of Services Reference Sheet to select the applicable description for the medical service(s) provided.

(d) Payment made by the CVCP for an FME must be considered as payment in full. CVCP is not bound by any billing or contractual agreements made between agencies and/or service providers.

(e) If the grand total for all bills (per application) exceeds $1,000, then a formula will be utilized to distribute equitable payments to each service provider up to $1,000 per victimization.

(f) For each victimization, CVCP will cover the cost of one FME per victim. If more than two FMEs are submitted in the same year for the same victim, any subsequent claims may be submitted to the CVCP Board for consideration.

(g) CVCP may conduct audits and/or site visits annually and, as needed, to ensure compliance with the preceding guidance and accuracy of reporting. Audits and/or site visits may include a review of forensic medical exam-related documentation and interviews with staff, including but not limited to the SANEs responsible for conducting the exams, victims' advocates and financial staff. A law enforcement verification document and any supplemental investigative documents may be obtained as part of the auditing process.

(h) Payments for FME's are funded by federal and/or state funds. Potential fraud, waste, abuse, or misconduct involving or relating to payments for FME's will be referred by CVCP to an appropriate investigative agency.

Notes

Ga. Comp. R. & Regs. R. 144-4-.08

O.C.G.A. §§ 17-15-1et seq., 35-6A-4.

Original Rule entitled "Forensic Medical Exams ("FMEs")" adopted. F. June 30, 2015; eff. July 20, 2015. Amended: F. July 9, 2019; eff. July 1, 2019, as specified by the Agency. Amended: F. Apr. 1, 2022; eff. Apr. 21, 2022.