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 B ­ GROUP APPEAL REQUEST Date of Request: _______________________ Proposed Group Name: ________________________________________________________________ _____________________________________________________________________________________ Fiscal Year Ended: _______________________ Intermediary/MAC: _____________________________________________________ 1. 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) 2. If mandatory group, provide the following contact information for the parent organization: Corporation Name: Contact Person at Corporation: Corporation Address: ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ Telephone Number: Fax Number: E-mail Address: 3. Preliminary Schedule of Providers: UNDER A TAB LABELED 1, YOU MUST 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. American LegalNet, Inc. www.FormsWorkFlow.com 4. 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 5. 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. 6. Is the Group requesting Mediation? NOTE: If yes, a request must be submitted in a separate document. _____ YES _____ NO 7. Group Representative Information: Representative Name: Company Name: Company Address: ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ Phone Number: Fax Number: E-mail Address: 8. Lead Intermediary/MAC Information: ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ Intermediary/MAC Code (if known): _______________________ 9. Common Group Issue Appealed (only one issue per group): ______________________________ _________________________________________________________________________________ NOTE: The matter at issue must involve a single common question of fact or interpretation of law, regulation or CMS Rulings that is common to each provider in the group. See 42 C.F.R. § 405.1837(a)(2) and PRRB Rules 13 and 8. UNDER A TAB LABELED 2, YOU MUST SUBMIT A STATEMENT OF THE GROUP ISSUE. The 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 must include: (1) a description of the issue; and (2) a statement identifying the legal basis for the appeal (with citation to statutes, regulations and/or manual provisions). American LegalNet, Inc. www.FormsWorkFlow.com Intermediary/MAC Name: Intermediary Address: 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 on this __________day of ______________, 2_____. Certified Mail or Tracking Number: _________________________________________ Signature: _______________________________________________ (Group Representative) Date: _______________________ American LegalNet, Inc. www.FormsWorkFlow.com