DEPARTMENT OF HEALTH & HUMAN SERVICES PROVIDER REIMBURSEMENT REVIEW BOARD 2520 Lord Baltimore Drive, Suite L Baltimore, MD 21244-2670 Phone: 410-786-2671 MODEL FORM B - GROUP APPEAL REQUEST Date of Request: ________________________________ Proposed Group Name: ________________________________________________________ Fiscal Year Ended: ______________________________ Intermediary/MAC: _______________________________________________ Type of Group (Check One): _______ Optional (providers are not commonly owned or controlled) _______ Mandatory (providers are commonly owned or controlled – Common Issue Related Parties (CIRP) Group) If mandatory group: name, contact information (include telephone & email address) and address of common owner/controlled organization: _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ UNDER A TAB LABELED 1 INCLUDE A LIST OF PROVIDERS THAT ARE APPEALING THE ISSUE USING THE FORMAT FOR THE SCHEDULE OF PROVIDERS WHICH CAN BE FOUND IN THE APPENDIX - MODEL FORM G. Complete the information required by each column including the original case number if applicable. Unless EJR is requested, only one provider in a CIRP group or two providers in an optional group must supply the representation letter and jurisdictional documentation required in the Schedule of Providers (See Rules 20-21) to establish jurisdiction for a group appeal. Jurisdictional documentation for all providers must be furnished in the final Schedule of Providers. Is this group fully formed (does it include all providers that will be in the group, and have all the providers received their final determinations)? _____ Yes ______ NO Does this Request for Hearing 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 or package transmitting this request.) Is the Provider’s Representative requesting mediation at this time? (If yes, a request must be submitted in a separate document.) _____ YES _____ NO American LegalNet, Inc. www.FormsWorkFlow.com Group Representative Information: Representative’s Name: _____________________________________________ Company Name and Address: ________________________________________ ________________________________________ ________________________________________ Phone Number: ___________________________________ FAX Number: ____________________________________ E-mail address: _________________________________________ Lead Intermediary/MAC Information: Intermediary/MAC Name: ___________________________________________ Address: ___________________________________________ ___________________________________________ ___________________________________________ Intermediary/MAC Code: _________________________________ (If known) Single Issue Under Appeal (1 per group): UNDER A TAB LABELED 2 YOU MUST SUBMIT A STATEMENT OF THE GROUP ISSUE. This statement of the issue must conform to the requirements of the regulations found at 42 C.F.R. § 405.1837 et seq. and the Board’s Rules and include a brief description of the issue and the legal basis for the appeal (Cite statutes, regulations and/or manual provisions.). 2 American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATIONS A. For Optional and Mandatory (CIRP) Groups: I hereby certify that the group issue filed under this appeal is not pending in any other appeal for the same period for the same provider, nor has it been adjudicated, withdrawn, or dismissed from any other PRRB appeal. Printed Name: ___________________________________ Title: ___________________________________________ Signature: ________________________________________ Group Representative Date: ____________________ B. For Optional (Non-CIRP) Groups Only: I hereby certify to the best of my knowledge that there is no other provider to which this provider is related by common ownership or control that has a pending request for a Board hearing on the same issue contained in this hearing request for a cost reporting period that ends in the same calendar year cover in this hearing request. See 42 C.F.R. § 405.1837(b)(1)(i). Printed Name: ___________________________________ Title: ___________________________________________ Signature: _______________________________________ Group Representative Date: ____________________ C. I certify that a copy of this Request (and all supporting documentation) was sent by (check one) _______ United States Postal Service _______ Nationally recognized courier. Specify name: ____________________________ to the lead Intermediary/MAC (if known) and the local Intermediary/MAC (if different) on this __________day of _________________, 2_____. Certified Mail or Tracking Number: _________________________________________ Signature: __________________________________ Group Representative Date: ______________________ 3 American LegalNet, Inc. www.FormsWorkFlow.com