CalVCB will review cosmetic surgery estimates to give providers and applicants advanced notice if CalVCB can reimburse the requested procedures and how much.
- Surgeon fee
- Facility fee
- Anesthesia fee
- CPT codes
- Costs for each category
- Other documentation showing the injuries are a direct result of the crime.
Providers are not required submit the estimate on a CMS 1500.
CalVCB will determine if the recommended service:
- is medically necessary; or
- will best aid the claimant; and
- is related to the qualifying crime.
CalVCB may request additional information.
An applicant does not have the right to appeal a preauthorization denial because they did not suffer a pecuniary loss. The applicant may still undergo the cosmetic surgery procedure and submit the incurred costs to CalVCB for reimbursement with the understanding CalVCB may not reimburse these costs.
- Patient’s name and address
- Date(s) of service
- Type(s) of service(s) provided (CPT codes)
- Billed amount
- Provider’s license number, federal tax identification number (FEIN or SSN), business address, telephone number, signature or signature stamp
- Billing date
The surgeon, facility, and anesthesia fees are paid at 80% of the billed amount. Facility and anesthesia fees are subject to be reimbursed at the Medicare rate if the procedures are outsourced to a different facility and not completed in-house.