Code R Service Providers

Payment Information Tables

• Please review the tables linked here based on date of service.

Required Documentation for Payment Review and Payment Information

• Submit a Fast Track Reimbursement Form
• Either the Fast Track Reimbursement Form or Code R related billing must be submitted within ONE YEAR from the date of the sexual assault forensic exam
• Submit either a UB-04 or a CMS-1500 billing form, along with the insurance Explanation of Benefits, if applicable
• Payment made by UOVC on behalf of a victim, when accepted by the provider, is considered payment in full

How to Submit Documents

FAX:  (801)533-4127

Email:  crimevictims@utah.gov

Mail:    Utah Office for Victims of Crime
             350 E. 500 S. Suite 200
             Salt Lake City, UT 84111

For additional questions

Contact the UOVC Provider Liaison

Amy Armstrong
(801)238-2377
aarmstrong@utah.gov