Rule 16 Procedure for claim determination
Rule Text
(a) Upon the receipt of verification requests, a claims examiner of the Program shall process and initially determine whether a claimant qualifies for program benefits. If the claimant is eligible for benefits, the claim examiner shall evaluate crime related losses, and:
(1) May refer claimant to collateral sources;
(2) Shall contact providers to confirm payments from collateral sources and/or the victim's receipt or entitlement to such payment;
(3) Shall compute entitlement to Program benefits;
(4) Shall prepare payment requests for approval by the Director and transmittal to the Budget and Finance Operations Division of the Superior Court; and
(5) Shall make appropriate deductions in compensation where the conduct of the victim in the crime causes a partial denial of compensation.
(b) If verification is not received, the claim may be processed, but the provider from whom pending documentation has not been received shall be sent a letter informing the provider that benefits will be considered only upon receipt of verification.
(c) Upon recommendation of denial of a claim, the claims examiner shall explain and document the reasons for denial, and forward the file to the Director for final decision.