Sexual Assault Services Providers

Billing

This page explains how sexual assualt services providers can submit billing to the Utah Office for Victims of Crime (UOVC) for eligible sexual assault related services.

Reminder: Providers must bill all available insurance or other payment sources before submitting claims to UOVC.

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Payment Information

Payment amounts for sexual assault forensic exams and related services are based on the UOVC payment tables. View the payment tables for eligible services.

Billing for sexual assault forensic exams or related services must be submitted within one year from the date of the service. This includes submissions using the Fast Track Reimbursement Form or provider billing.

Payment in Full Requirement

A sexual assault exam service provider who accepts payment from UOVC agrees to accept that payment as payment in full on behalf of the patient and may not attempt to collect additional payment from the patient.

Submitting Billing for Payment Review

Submit the following:

  • Fast Track Reimbursement Form (if used)
  • UB-04 or CMS-1500 billing form
  • Insurance Explanation of Benefits (EOB), if applicable
  • Documentation showing services are crime-related

CMS-1500 Billing Form

PDF

UB-04 Billing Form

PDF

Fast Track Reimbursement Form – SA Services Providers

PDF
DOCX

Submit Billing Documents

Choose a submission method:

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