Payments for Sexual Assault Forensic Examinations

PURPOSE: This rule sets out the reporting and billing procedures for appropriate medical providers who conduct sexual assault forensic examinations, commonly known as SAFE exams. This rule sets out the requirements for the appropriate medical provider in submitting a SAFE exam claim to the Department of Public Safety for payment. This rule also establishes the criteria by which SAFE exam expenses are paid and sets out the maximum payments for SAFE exams performed at an emergency room and the maximum payments for SAFE exams performed at a clinic. (1) For purposes of this section, the following terms mean: (A) “Appropriate medical provider,” any licensed nurse, physician, or physician assistant, and any institution employing licensed nurses, physicians, or physician assistants, provided that such licensed professionals are the only persons at such institution to perform tasks under the provisions of this section; (B) “Child abuse medical resource centers,” medical institutions affiliated with accredited children’s hospitals or recognized institutions of higher education with accredited medical school programs that provide training, support, mentoring, and peer review to Sexual Assault Forensic Examination – Child Abuse Resource and Education (SAFE-CARE) providers in Missouri; (C) “Sexual assault forensic examination child abuse resource education network” or “SAFE-CARE network,” a network of SAFECARE providers and child abuse medical resource centers that collaborate to provide forensic evaluations, medical training, support, mentoring, and peer review for SAFECARE providers for the medical evaluation of child abuse victims in this state to improve outcomes for children who are victims of, or at risk for, child maltreatment by enhancing the skills and role of the medical provider in a multidisciplinary context; (D) “SAFE-CARE provider,” a physician, advanced practice nurse, or physician’s assistant licensed in this state who provides medical diagnosis and treatment to children suspected of being victims of abuse and who receives— 1. Missouri-based initial intensive training regarding child maltreatment from the SAFE-CARE network; 2. Ongoing update training on child maltreatment from the SAFE-CARE network; and 3. Peer review and new provider mentoring regarding the forensic evaluation of children suspected of being victims of abuse from the SAFE-CARE network; (E) “Evidentiary collection kit,” a kit used during a forensic examination that includes materials necessary for appropriate medical providers to gather evidence in accordance with the forms and procedures developed by the attorney general for forensic examinations; (F) “Forensic examination” or “Sexual Assault Forensic Examination (SAFE) exam,” an examination performed by an appropriate medical provider on a victim of an alleged sexual offense to gather evidence for the evidentiary collection kit or using other collection procedures developed for victims who are minors; (G) “Medical treatment,” the treatment of all injuries and health concerns resulting directly from a patient’s sexual assault or victimization; (H) “Laboratory fees,” those laboratory fees associated with a forensic examination of a child age thirteen (13) or under or those laboratory fees associated with lab tests which the appropriate medical provider deems necessary to determine whether the victim had been drugged; (I) “Emergency forensic examination,” an examination of a person under fourteen (14) years of age that occurs within five (5) days of the alleged sexual offense; and (J) “Non-emergency forensic examination,” an examination of a person under fourteen (14) years of age that occurs more than five (5) days after the alleged sexual offense. (2) The victim or the victim’s parent or guardian shall consent in writing to the examination. If the victim is a minor, then a representative from the requesting agency which is referring the victim for the exam, such as law enforcement or Children’s Division, may sign for consent of the forensic exam. (3) Claims for payment of forensic examination expenses shall be submitted to, and received by, the Missouri Department of Public Safety, Sexual Assault Forensic Examination (SAFE) Program within ninety (90) days from the date of the forensic examination. (4) Claims shall be made on the Sexual Assault Forensic Examination Program Report form approved by the Missouri attorney general. The appropriate medical provider must ensure that all lines of the report form are completely and legibly filled out. The appropriate medical provider shall sign and date the report. If the report is incomplete, unsigned, or not dated, the claim may be denied. (5) To qualify for payment, all claims shall include the Sexual Assault Forensic Examination Program Report, the Sexual Assault Forensic Examination Checklist, and an itemized billing statement. (6) For billing purposes, all appropriate charges for the sexual assault forensic examination shall be itemized with each billable procedure, service, or supply described, including the accompanying International Classification of Disease (ICD-9) and Current Procedural Terminology (CPT) code(s). Written explanation and reasoning may be required to justify certain codes. (7) To qualify for payment on claims for a non-emergency forensic exam, physicians, advance practice nurses (APRN), or physician assistants (PA) must meet at least one (1) of the following criteria: (A) Child Abuse Pediatrics Sub-board eligibility or Certificate of Added Qualification; or (B) A SAFE-CARE provider. (8) To qualify for payment on claims for a non-emergency forensic exam, licensed nurses must meet the following criteria: (A) Pediatric Sexual Assault Nurse Examiners (SANE) certification (if performing exams on children age thirteen (13) or younger); (B) Meet all SAFE-CARE training requirements; and (C) Review of the exam by a health care provider who is a SAFE-CARE provider. (9) Emergency forensic exams performed by an appropriate medical provider including advance practice nurses (APRN) will be reimbursed provided that the incident meets the following criteria: (A) The alleged assault may have resulted in the transfer of trace biological material; or (B) The alleged assault may have placed the child at risk for pregnancy; or (C) The child complains of pain in the genital or anal area related to the disclosure of sexual abuse; or (D) There is evidence or complaint of anogenital bleeding or injury. (10) Payment shall not exceed— (A) Nine hundred dollars ($900) for forensic exams performed in an emergency room, including all costs associated with the facility and the appropriate medical provider fee. 1. When the exam is performed by a physician, physician assistant, or an advanced practice nurse in an emergency room, payment shall not exceed— A. Five hundred forty dollars ($540) for the emergency room fee; and B. Three hundred sixty dollars ($360) for the provider fee if submitted separately; 2. When the exam is performed in an emergency room by an appropriate medical provider other than a physician, physician assistant, or an advanced practice nurse, payment shall not exceed— A. Six hundred forty dollars ($640) for the emergency room fee if submitted separately; and B. Two hundred sixty dollars ($260) for the provider fee if submitted separately; (I) If a non-emergency sexual assault forensic examination is performed on a child age thirteen (13) or younger by a provider under this subsection who is not a SAFE-CARE provider and the exam is reviewed by a SAFE-CARE provider, then the provider will receive one hundred and ten dollars ($110) and the SAFE-CARE provider will receive one hundred and fifty dollars ($150). (II) If a non-emergency sexual assault forensic examination is performed on a child age thirteen (13) or younger by a provider under this subsection who is not a SAFE-CARE provider and the exam is not reviewed by a SAFE-CARE provider, then payment will not issue; (B) Six hundred fifty dollars ($650) for forensic exams performed in a clinic, including all costs associated with the facility and the appropriate medical provider. 1. When the exam is performed by a physician, physician assistant, or an advanced practice nurse in a clinic, payment shall not exceed— A. Two hundred ninety dollars ($290) for the clinic fee if submitted separately; and B. Three hundred sixty dollars ($360) for the provider fee if submitted separately; and 2. When the exam is performed in a clinic by an appropriate medical provider other than a physician, physician assistant, or an advanced practice nurse, payment shall not exceed— A. Three hundred ninety dollars ($390) for the clinic fee if submitted separately; and B. Two hundred sixty dollars ($260) for the provider fee if submitted separately; (I) If a non-emergency sexual assault forensic examination is performed on a child age thirteen (13) or younger by a provider under this subsection who is not a SAFECARE provider and the exam is reviewed by a SAFE-CARE provider, then the provider will receive one hundred and ten dollars ($110) and the SAFE-CARE provider will receive one hundred and fifty dollars ($150). (II) If a non-emergency sexual assault forensic examination is performed on a child age thirteen (13) or younger by a provider under this subsection who is not a SAFE-CARE provider and the exam is not reviewed by a SAFE-CARE provider, then payment will not issue; and (C) Two hundred dollars ($200) for any laboratory fees associated with the forensic examination, whether the forensic examination is conducted at an emergency room or clinic. (11) The billing statement must include an itemization of the charges incurred while conducting the forensic examination, including, if applicable, the itemized laboratory fees. (12) For the purposes of billing the Sexual Assault Forensic Examination Program, claims shall not include charges for medical procedures that are not part of the SAFE exam. The SAFE Program shall not pay for any portions of the itemized bill that are not part of the SAFE exam. The SAFE Program shall not pay for any laboratory fees associated with a SAFE exam except for qualified laboratory fees. (13) Only one (1) forensic examination per victim per sexual offense may be reimbursed. (14) For a forensic examination to be eligible for reimbursement by the SAFE Program— (A) The victim of the alleged sexual offense must be a Missouri resident; or (B) The alleged sexual offense must have occurred in Missouri. (15) The department, at its discretion, may require additional information regarding the forensic examination for auditing purposes. AUTHORITY: section 595.220, RSMo Supp. 2013.* Emergency rule filed Dec. 7, 2011, effective Dec. 17, 2011, expired June 13, 2012. Original rule filed Dec. 7, 2011, effective Aug. 30, 2012. Amended: Filed Feb. 2, 2015, effective July 30, 2015. *Original authority: 595.220, RSMo 2009, amended 2011.