DEPARTMENT OF HEALTH & HUMAN SERVICES PROVIDER REIMBURSEMENT REVIEW BOARD 2520 Lord Baltimore Drive, Suite L Baltimore, MD 21244-2670 Phone: 410-786-2671 Fax: 410-786-5298 MODEL FORM A ­ INDIVIDUAL APPEAL REQUEST Date of Request: _______________________ Provider Name: _____________________________________________________ Provider Number: _______________________ Fiscal Year Ended: _______________________ Intermediary/MAC: _____________________________________________________ 1. Date of Notice of Final/Revised Determination: _______________________ Type of Final Determination: _____ Notice of Program Reimbursement (NPR) (Check one) _____ Revised NPR _____ Exception Determination _____ Federal Register Notice _____ Failure to Issue a Timely Determination _____ Other (Specify: ________________________________) YOU MUST ATTACH A COPY OF THE FINAL/REVISED DETERMINATION UNDER A TAB LABELED 1. * If appealing from a Revised NPR, you MUST also provide copies of: (1) the NPR immediately preceding the Revised NPR under appeal, (2) the Reopening Request that preceded the Revised NPR (if applicable), (3) the Reopening Notice issued by the Intermediary, (4) the Revised NPR workpapers (for the issue(s) under appeal), and (5) any applicable cost report worksheets (e.g., Worksheet E). See Rule 7.1. * If claiming Intermediary/MAC failed to issue a timely Final Determination, state the date the cost report was sent to the Intermediary: _______________________. You MUST also include copies of: (1) the certification page of the perfected or amended cost report, (2) the certified mail receipt evidencing the Intermediary's receipt of the as-filed and any amended cost reports, (3) the Intermediary's letter or e-mail acknowledging receipt of the as-filed and any amended cost reports, (4) evidence of the Intermediary's acceptance or rejection of the as-filed and any amended cost reports, and (5) the documentation described in Rule 7.2, as relevant, if the issue(s) being appealed involves one or more self-disallowed items. See Rule 7.4. * If receipt of Final/Revised Determination is more than five days after date of determination, state date received: _______________________. You MUST also include a copy of documentation to support the actual date of receipt. American LegalNet, Inc. www.FormsWorkFlow.com 2. Does this Request include a request for Expedited Judicial Review? _____ YES _____ NO NOTE: A request for EJR must be submitted in a separate document and "EJR Request" must be marked on the outside of the envelope. 3. Is the Provider requesting Mediation? NOTE: If yes, a request must be submitted in a separate document. _____ YES _____ NO 4. Provider Information: Provider Name: Provider Contact/Title: Provider Address: ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ Provider Telephone Number: Provider Fax Number: E-mail Address: 5. Is this Provider commonly owned or controlled? _____ YES NOTE: If yes, identify the following contact information for the parent organization: Corporation Name: Contact Person at Corporation: Corporation Address: _____ NO Telephone Number: Fax Number: E-mail Address: ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ 6. Intermediary/MAC Information: ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ Intermediary/MAC Code (from NPR, if known): _______________________ Intermediary/MAC Name: Intermediary Address: American LegalNet, Inc. www.FormsWorkFlow.com 7. Representative Information (if applicable): Representative Name: Company Name: Company Address: ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ Phone Number: Fax Number: E-mail Address: NOTE: If you are filing as a representative, YOU MUST ATTACH A LETTER SIGNED BY THE PROVIDER AUTHORIZING REPRESENTATION UNDER A TAB LABELED 2. See Rule 5.4. 8. Issue(s) Appealed: UNDER A TAB LABELED 3, YOU MUST SUBMIT A STATEMENT OF THE ISSUE(S). The statement of the issue(s) must conform to the requirements of the regulations found at 42 C.F.R. § 405.1835 et seq. and the Board's Rules and must include: (1) a description of the issue; (2) the audit adjustment number(s), if applicable, or other evidence required by 42 C.F.R. § 405.1835 (a)(1)(ii); (3) the amount in controversy; and (4) a statement identifying the legal basis for the appeal (with citation to statutes, regulations and/or manual provisions). Total Amount in Controversy for all Issues: _______________________ American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATIONS A. I certify that none of the issues filed in this appeal are pending in any other appeal for the same period and provider, nor have they been adjudicated, withdrawn, or dismissed from any other PRRB appeal. Printed Name: _______________________________________________ Title: _______________________________________________ Signature: _______________________________________________ (Provider Owner/Officer/Director or Representative) Date: _______________________ B. I certify to the best of my knowledge that there are no other providers to which this provider is related by common ownership or control that have a pending request for a Board hearing on any of the same issues for a cost reporting period that ends in the same calendar year covered in th