Legal Requirements
        • The application must be submitted by the provider who performed the forensic medical exam, 
          with the signed consent, itemized bills and medical records, within 180 days of the 
          date of the exam
        • The patient is the victim of a sex crime that occurred in the State of Indiana.  
        • Victims 18 years of age and over are not required to report to law enforcement
        • If the patient is under 18 years of age, a parent or guardian must give consent in writing 
          as the responsible party and Law Enforcement and/or Department of Child Services must be notified  
        • The sex crime victim must consent to the forensic medical exam; and must consent in writing 
          to allow the medical facility to file an application for reimbursement and release his/her medical
          records to The Division
        • The Sexual Assault Compensation Program is the primary payer.Providers may bill a victim’s 
          insurance, Medicaid, Medicare or other third party payer only with the written consent of the victim
        • It is against the law to bill the victim for services that are eligible for coverage under the 
          sexual assault reimbursement program, even if the payment from CJI is delayed or denied.  
        • The provider may bill the patient for services not coverable under the program

    Reimbursable Expenses
        • Covers only specific services, included but not limited to:
            –	Initial Emergency Room Treatment & Forensic Medical Exam
            –	Hospital medications, limited laboratory & x-ray services
            –	Emergency treatment of wounds/injuries experienced as a direct result of the sexual assault
            –	Medically necessary ambulance transportation to the emergency room
            –	Up to $3,000 in out-patient counseling, provided on an individual basis, 
                for issues related to the sexual assault.  
                    • Reimbursement can be issued only for services provided by a licensed mental 
                      health provider
            –	Initial Pregnancy & STD testing
                    • One follow-up pregnancy test and other STD testing up to 30 days following the first 
                      emergency room treatment
                    • One Syphilis test up to 90 days following the initial exam
                    • Prophylactic medication related to pregnancy or sexually transmitted diseases, 
                      excluding HIV and Hepatitis

    Expenses That Are Not Reimbursable
        • Any service not specifically listed above
        • Follow-up treatment of physical injuries sustained during the sexual assault
             • If the victim is subsequently admitted to the hospital on an in-patient 
               basis following emergency room treatment, or if the victim requires additional follow-up 
               treatment of injuries that occurred during the sexual assault, the patient may apply to
               The Division and meet separate eligibility requirements via the Violent Crime Victim 
               Compensation program

    How To Apply 
    The application must be submitted by the provider who performed the forensic medical exam.  
    The application must include the victim’s dated signature & initials on The Division’s consent form,
    authorizing the provider to submit the application and release information; itemized bills and 
    medical records.  All of the above information must be submitted within 180 days of the date of the exam

    Applications may be submitted on-line, by mail, fax, e-mail, or in person to The Division.  
    Paper applications can be requested by contacting ICJI’s office. 

    Paper applications and supporting documentation may be submitted by fax:  317-233-3912;
    or by mail at:  Indiana Criminal Justice Institute, Victim Compensation Division, 
    Sexual Assault Reimbursement Program, 
    101 W. Washington Street, Suite 1170 East, Indianapolis, IN 46204.

    What Happens Next?
    The Division reviews all applications, consent, medical records and charges to determine eligibility. 
    If the application is not complete or the medical provider has not mailed the consent, 
    medical records or itemized bill; the Division will request that information in writing.  
    The provider has thirty (30) days to provide the requested information. 
    If The Division does not receive the required information, the application may be denied. 
    Providers may not bill sexual assault victims for eligible services that have been denied.  

    Once all information is received The Division will approve eligible charges for payment. 
    An acknowledgement letter is sent to providers to advise them the amount the fund will reimburse.
    Providers may not bill the victim for eligible services, even if payment is delayed or denied. 

    Checking The Status of Your Application
    The provider who submitted the application will be able to check the status of their application. 
    When your application is received, ICJI will send an acknowledgement letter containing the claim 
    number assigned to the application.  Providers will log on using their Federal Tax ID# as 
    their username and their Indiana Vendor Number as their password, and will need to enter 
    the claim number to access status information.  

    What If I Don’t Agree With The Decision? Providers have thirty (30) days from the date of the
    notice to send a written request for an appeal. This request should include a brief description
    of why you disagree with the determination, and copies of any documentation that supports your 
    request.  The Division will re-open the file for further review or schedule a hearing before
    an Administrative Law Judge.  Appeal hearings are held telephonically, or upon request,
    in person at the Indiana Criminal Justice Institute office in Indianapolis. 

    Contact Information:
    If you have questions about the Sexual Assault Reimbursement program you may contact
    The Division using the link below:

    You may also contact us by telephone: toll-free at (800) 353-1484, by fax:  317-233-3912; 
    or by mail at:  Indiana Criminal Justice Institute, 
    Victim Compensation Division,  101 W. Washington Street, Suite 1170 East, Indianapolis, IN 46204.