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 D - REQUEST TO TRANSFER ISSUE TO A GROUP APPEAL YOU MUST FILE AN ORIGINAL AND 1 COPY OF THIS FORM (MARKED COPY) Date of Request: _____________________________ Original PRRB Case No.: _____________________________ Provider Name: _____________________________________________ Provider No.: ________________________________ FYE: _______________________________________ Is this the last issue remaining in the individual appeal? If so, check Yes and the individual case will be closed due to the transfer of the remaining issue. _____ Yes ______ No PRRB Group Case Number to which issue is being transferred: _____________________ Is this a commonly owned or controlled Provider? _____ YES _____ NO Is this a common issue related party (CIRP) group appeal? _____ YES _____ NO Is the Provider a member of the CIRP? _____ YES _____ NO Note: (See Rule 12.5) Independent hospitals may not participate in CIRP groups. If you are a CIRP provider who is attempting to transfer an issue to a group appeal involving independent hospitals, you must document why this action is appropriate in the space below (An example of an appropriate response is that the provider certifies that no other commonly owned providers have nor will have the same issue pending. __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Description of Issue that is being transferred: __________________________________________________________________________________ (Include audit adjustment number if applicable.) Was the issue included in the Provider’s initial appeal? _____ YES _____ NO If “NO”~ Was the issue added to the Provider’s pending appeal? ______ YES ______ NO NOTE: The issue must be included in the individual appeal before it can be transferred to a group appeal. See, 42 C.F.R. § 405.1835. American LegalNet, Inc. www.FormsWorkFlow.com Are you the representative for the individual appeal from which the issue is being transferred? _____ YES _____ NO If “NO”, you will be required to submit an authorization of representation signed by an official of the Provider when you submit the final Schedule of Providers with the associated jurisdictional documentation. IF THE GROUP APPEAL TO WHICH YOU ARE REQUESTING TO TRANSFER HAS NOT BEEN ASSIGNED A CASE NUMBER, PLEASE PROVIDE THE FOLLOWING INFORMATION OR A COPY OF THE REQUEST FOR A GROUP: Date of Group Appeal Request: ____________________ Group Representative’s Name: ________________________________________ Group Representative’s Contact Information: ________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ Proposed Name of Group Appeal: _____________________________________________________ NOTE: Transfers using this form can only be made to existing group appeals and to group appeals that have been requested previously, but which have not yet been assigned a case number by the Board. If you attempt to transfer an issue to a group case that has not yet been requested to be established, your transfer request will not be processed and the issue will remain in the individual appeal. 2 American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATIONS A. I certify that this issue is not pending in any other appeal for the same period, nor has it been adjudicated, withdrawn, or dismissed from any other PRRB appeal. The Provider has been notified that this issue is being transferred to the group appeal case number _____________. The Provider agrees with this transfer. Printed Name: _______________________________________ (Provider/Rep. Transferring Issue) Signature: __________________________________________ Date: _______________________ B. I have reviewed the regulations at 42 C.F.R. § 405.1837, the Board Rules and consulted with the other representative identified on this form. I have a good faith belief that this transfer request meets the single common issue requirement for a group appeal. Signature: _______________________________ (Provider/Rep. Transferring Issue) Signature: ________________________________ (Group Rep.) Date: _______________________ Date: ______________________ C. I certify that a copy of this Request (and any 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 Rep.) Date: _________________ 3 American LegalNet, Inc. www.FormsWorkFlow.com