LAC 50:XXII.4901. Submission Requirements

A. Requests for payment must be “person specific” for each Hurricane Katrina or Rita evacuee or other affected individual. The request must contain the following data, if known, for the evacuee or other affected individual: 1. last name; 2. first name; 3. middle initial; 4. Social Security number; 5. date of birth; 6. residential address the week prior to Hurricane Katrina or Hurricane Rita; 7. parish of residence the week prior to Hurricane Katrina or Hurricane Rita; 8. date(s) of service; and 9. any other identifying data that would assist in establishing the recipient’s identity in the absence of any of the items cited in paragraphs 1-8 above. B. Providers may submit requests for payment of costs incurred during the following time periods: 1. dates of service from August 24, 2005 through January 31, 2006 for Hurricane Katrina; and 2. dates of service from September 23, 2005 through January 31, 2006 for Hurricane Rita. C. Providers shall be required to sign an attestation that confirms that: 1. the services provided were medically necessary; 2. they have not received payment from any other source; 3. they will not subsequently bill another source for payment; 4. they are not aware of any other payment source for the services rendered; and 5. payment will be accepted as payment in full for the services rendered. D. The deadline for submission of all payment requests is June 30, 2006.