Section Jus 604.08 - Mental Health Assessment and Treatment Plan(a) If a claimant seeks compensation for mental health expenses, the victim or victim's parent or guardian shall complete and submit a HIPAA compliant hospital and/or medical release. Upon receipt of the HIPAA compliant release form, the unit shall request that each provider complete and submit a "Mental Health Assessment and Treatment Plan Form," effective 1/14/19. (b) All information provided on or with the "Mental Health Assessment and Treatment Plan" will be kept strictly confidential. This information shall not be disclosed to anyone outside of the NH Victims' Compensation commission and Compensation staff, without the express written permission of the victim, claimant, the provider, or under court order.(c) By his or her signature on the 'Mental Health Assessment and Treatment Plan Form', effective 1/14/19, the provider shall agree to the following: (1) I am a licensed therapist who is experienced in working with the victims of trauma;(2) Under the laws and rules applicable to the Commission, that the Victims' Compensation Program is the payer of last resort and all private insurance and/or federal or state funding, including Medicaid and Medicare, must be billed first;(3) I will accept the NH Victims' Compensation Program's reimbursement of $75 for an individual, crime-related, therapy session and $35 for a group, crime-related, therapy session as payment in full;(4) I understand that I may only bill the Victims' Compensation Program for crime-related therapy.(5) I will request any necessary extension of treatment 30 days prior to the end of all Commission approved sessions.;(d) The provider shall complete this form only after personally meeting with the victim.(e) The Victims' Compensation program shall only pay for crime-related counseling expenses and shall only provide payment for licensed therapists.(f) The provider shall submit an itemized statement and medical records relating to injuries directly resulting from the crime.(g) The monetary cap on mental health treatment shall be $4,000.00 or 40 visits, whichever occurs first.N.H. Admin. Code § Jus 604.08
Amended by Volume XL Number 2, Filed January 9, 2020, Proposed by #12938, Effective 12/9/2019, Expires 12/9/2029.