Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-30 - Rules for the administration of the crime victims compensation program › Section 296-30-010 - Definitions

Current through Register Vol. 24-14, July 15, 2024
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. Non-medical 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.
Statutory Authority:
				  Chapter
				  7.68 RCW. 11-22-054, §
				  296-30-010, filed 10/31/11, effective 12/1/11. Statutory Authority:
				  RCW
				   7.68.030. 01-22-105, § 296-30-010, filed
				  11/7/01, effective 12/8/01; 00-10-003, § 296-30-010, filed 4/20/00,
				  effective 5/22/00. Statutory Authority:
				  RCW
				   51.36.010,
				  7.68.030,
				  51.04.020(1) and
				  (4),
				  51.04.030,
				  7.68.080 and
				  7.68.120. 97-02-090, §
				  296-30-010, filed 12/31/96, effective 1/31/97. Statutory Authority:
				  Chapter
				  7.68 RCW. 94-02-015, §
				  296-30-010, filed 12/23/93, effective 1/24/94. Statutory Authority:
				  RCW
				   7.68.030,
				  7.68.070(12) and
				  (16)  and
				  51.04.030. 89-23-004, §
				  296-30-010, filed 11/3/89, effective 11/10/89. Statutory Authority:
				  Chapter
				  7.68 RCW. 86-01-028 (Order
				  85-37), § 296-30-010, filed 12/11/85; 85-03-060 (Order 85-3), §
				  296-30-010, filed 1/15/85.