Code R Service Providers


PAYABLE SERVICES:

PAYMENT/ALLOWABLE AMOUNT

Sexual Assault Code R Exams

 

$375 maximum allowable amount

Sexual Assault Code R Exams with Photo Documentation

 

 

$750 maximum allowable amount

HIV Prophylaxis Medication

PEHP (Public Employees Health Plan) Allowable Amounts

Initial Emergency Room Visit:

  •      Use of the Emergency Room
  •      STD Testing
  •      Pregnancy Testing
  •      Related Medications

 

  • 60% of billed amount up to maximum of $350
  • 60% of billed amount or patient responsibility after insurance
  • 60% of billed amount or patient responsibility after insurance
  • 60% of billed amount or patient responsibility after insurance

Follow Up STD Testing and Treatment completed within the first 4 weeks from the date of the forensic exam

 

60% of the billed amount or patient responsibility after insurance

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