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Do not bill the patient/victim. The facility shall bill the Criminal Injuries Compensation Fund.

This pertains to persons of sexually-oriented crimes under Tennessee Code Annotated, Section 39-13-502—39-13-506, 39-13-522, 39-13-531, 39-13-532, and 39-13-527 that occurred on or after July 1, 2007. This may include an exam for a crime occurring in Tennessee whether or not it is performed for a Tennessee resident. Payments for exams arising from crimes occurring outside Tennessee cannot be considered if that state has a forensic exam payment program which would pay any part of the expense.

The facility must provide an itemized bill (or UB-92 or UB-04 form with proper coding) and the Sexual Assault Forensic Examination Reimbursement Form on the reverse of this document. These items must be legible and complete for consideration.

The Division of Claims Administration may request clarifying information from the facility if required for payment of the bill, or may return incomplete documents.

In accordance with Tennessee Code Annotated, Section 29-13-118, the amount reimbursed by the Division/Fund must be accepted as payment in full. The facility cannot bill the patient a balance, for any reason.

The maximum available for all such examination-related expenses is $750.

Although the person may elect to report the crime, a report to law enforcement or cooperation with the prosecution is not required for payment of the exam.

The documents must be submitted to the Division of Claims Administration within one (1) year of the date of the exam. Payment shall be rendered within ninety (90) days of receipt of request.

Medical treatment for injury may be billed separately and directly to a patient/victim, who then may file a claim for Criminal Injuries Compensation.

Submit itemized bill and the proscribed reimbursement form to:
Criminal Injuries Compensation Fund
SAFE Reimbursement
Division of Claims Administration
502 Deaderick Street
Nashville, TN 37243-0202