The following definitions are used to administer the crime victims compensation program:
Acceptance, accepted condition: A determination by the department that the diagnosis of the claimant's medical or mental health condition is the result of the criminal act. The condition being accepted must be specified by one or more diagnostic codes from the current edition of the International Classification of Diseases, Clinically Modified (ICD-CM), or the Diagnostic and Statistical Manual of Mental Disorders (DSM).
Authorization: Notification by a qualified representative of the department that specific treatment, services or equipment provided for the accepted condition is allowable under the claim. Providers must maintain records naming the claim manager who authorizes treatment, services or equipment.
Bodily injury: Any harmful or offensive touching, including severe emotional distress where no touching takes place when:
(1) The victim is not the object of the criminal act and:
(a) The distress is intentionally or recklessly inflicted by extreme or outrageous conduct;
(b) Caused the victim to have a reasonable apprehension of imminent bodily harm; and
(c) The victim is in the immediate vicinity at the time of the criminal act.
(2) The victim is the object of the criminal act and:
(a) The distress is intentionally or recklessly inflicted by extreme or outrageous conduct; and
(b) Caused the victim to have a reasonable apprehension of imminent bodily harm.
Claimant: A victim who submits an application for benefits, or on whose behalf an application is submitted.
Consultation: The services rendered by a health care provider whose opinion or advice is requested by the treating provider, or by the department, in the evaluation and/or treatment of a claimant. Case management or case staffing does not constitute a consultation.
Criminal act: An act defined in RCW
7.68.020, the occurrence of which can be verified by the department or which is reasonably credible. Physically impossible acts, highly improbable acts for which verification is not available, or unverified memories of acts occurring prior to the age of two will not be accepted as reasonably credible. In evaluating evidence to determine verification of claimed criminal acts, the department will give greater weight to the quality, than to the quantity, of evidence. Evidence that can be considered for verification of claimed criminal acts includes, but is not limited to, one or more of the following:
(1) Police or other investigation reports.
(2) Child protective services or other government agency reports.
(3) Diaries or journals kept by victims and others.
(4) Third party reports from school counselors, therapists and others.
(5) Current medical examinations.
(6) Medical or psychological forensic evaluations. In the absence of other adequate forensic evaluation reports, independent assessments per WAC
296-31-069 may be conducted when indicated.
(7) Legal and historical reports.
(8) Current and past medical and mental health records.
(9) Reports of interviews with the victim's family members, friends, acquaintances and others who may have knowledge of pertinent facts. When such interviews are necessary to determine eligibility, the victim will be given the choice of whether to allow the interviews to be conducted. The victim will also be given the understanding that eligibility may be denied if the interviews are not conducted. The department will act according to the victim's choice.
Crisis intervention: Therapy to alleviate the claimant's most pressing problems. The vital mental and safety functions of the claimant are stabilized by providing support, structure and, if necessary, restraint.
Evidence-based and curative treatment: Treatment practices, interventions and services that are supported by empirically based research and shown to produce consistent and effective outcomes.
Family therapy: Therapy involving one or more members of the claimant's family, excluding the perpetrator, which centers on issues resulting from the claimant's sexual assault pursuant to WAC
296-30-080.
Group therapy: Therapy involving the claimant, and one or more clients who are not related to the claimant, which includes issues related to the claimant's condition and pertinent to other group members.
Immediate family members: Any claimant's parents, spouse, child(ren), siblings, grandparents, and those members of the same household who have assumed the rights and duties commonly associated with a family unit.
Individual therapy: Therapy provided on a one-to-one basis between a provider and client.
Lost wage certification: Documentation from a treating provider based on objective medical evidence stating the claimant is not able to work based on the effects of the crime injury.
Maximum benefit: The maximum amount payable per claim. Medical benefits cannot exceed one hundred fifty thousand dollars per claim pursuant to RCW
7.68.085. Nonmedical benefits cannot exceed forty thousand dollars pursuant to RCW
7.68.070(1).
Mental health provider: Any person, firm, corporation, partnership, association, agency, institution, or other entity providing any kind of mental health services related to the treatment of a claimant. This includes, but is not limited to, hospitals, psychiatrists, psychologists, advanced registered nurse practitioners with a specialty in psychiatric and mental health nursing, registered and/or licensed master level counselors, and other qualified service providers licensed, registered and/or certified with the department of health and registered with the crime victims compensation program. (Refer to WAC
296-31-030 for specific details.)
Payer of last resort: The crime victims compensation program pays after all other public or private insurance programs, up to our fee schedule.
Proper and necessary: Proper and necessary services for the diagnosis or rehabilitative treatment of an accepted condition:
(1) Reflective of accepted standards of good practice within the scope of the provider's license, certification, or registration;
(2) Not delivered primarily for the convenience of the claimant, the claimant's attending provider, or another provider;
(3) Curative or rehabilitative care that produces long lasting changes which reduces the effects of the accepted condition;
(4) Provided at the least cost and in the least intensive setting of care consistent with the other provisions of this definition; and
(5) Concluded once a claimant has reached a state of maximum improvement. Maximum improvement occurs when no fundamental or marked change in an accepted condition can be expected with or without treatment. A claimant's condition may have reached maximum improvement though it might be expected to improve or deteriorate with the passage of time. Once a claimant's condition has reached maximum improvement, treatment that results only in temporary changes is not proper and necessary. Maximum improvement is equivalent to fixed and stable.
Reasonable cooperation: The victim is able to talk to the police and give information to help in the investigation and prosecution of the alleged offender. There may be circumstances in which the victim is not able to fully cooperate. In these instances, consideration is given to the needs of the victim. The department may consider the following issues. The list is not inclusive:
(1) There is fear of retribution from the offender;
(2) There is a mental or physical condition which inhibits cooperation;
(3) The victim is dependent upon the offender for support;
(4) The victim is a minor.
Termination of treatment: Treatment is concluded when it is no longer curative because the accepted condition for which the claim was allowed has become stable. The provider shall submit a report indicating the date the condition became stable to the department.
The result of: The test used to define "the result of" used in RCW
7.68.060 (2)(a) is two-pronged. First, it must be determined that cause in fact exists, and second, it must then be determined that proximate cause exists.
(1) Cause in fact exists if "but for" the acts of the victim the crime that produced the injury would not have occurred.
(2) Proximate cause exists if, once cause in fact is found, it is determined that the acts of the victim:
(a) Resulted in a foreseeable injury to the victim;
(b) Played a substantial role in the injury; and
(c) Were the direct cause of the injury.
Treating provider: A person licensed to practice one or more of the following professions: Medicine and surgery, osteopathic medicine and surgery, chiropractic naturopathic physician, podiatry, dentistry, optometry, advanced registered nurse practitioner (ARNP), mental health therapists, and certified medical physician assistants or osteopathic physician assistants. A treating provider actively treats an injured or ill claimant.
Unjustly enriched: It would not be fair or equitable justice to allow a person to obtain, or have control of, or access to benefits or compensation paid to a victim of crime.