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 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: _______________________ Prior PRRB Case No(s).: _______________________ (NOTE: You MUST provide full transfer history if issue has presided in more than one case.) Provider Name: _____________________________________________________ Provider Number: _______________________ Fiscal Year Ended: _______________________ 1. Describe the Issue that is being transferred and include the relevant audit adjustment number, if applicable: _________________________________________________________________________________ _________________________________________________________________________________ 2. Is this the last issue remaining in the individual appeal? _____ YES _____ NO If so, check Yes and the individual case will be closed due to the transfer of the remaining issue. 3. What is the PRRB Group Case Number and name of the group to which the issue is being transferred? Group Case No.: _______________________ Group Case Name: _____________________________________________________________ NOTE: If the group appeal to which you are requesting to transfer has not yet been assigned a case number, please provide the following information OR attach a copy of the group appeal request: Date of Group Appeal Request: Group Representative's Name: Group Representative's Company: 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. American LegalNet, Inc. www.FormsWorkFlow.com 4. Is this a commonly owned or controlled Provider? _____ 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: ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ 5. Is the group a mandatory Common Issue Related Party (CIRP) group appeal? _____ YES _____ NO 6. Is the Provider a member of the CIRP? _____ YES _____ NO NOTE: (See Rules 12.5 and 12.6.) Providers that are commonly owned or controlled must bring a group appeal for any issue common to the related Providers and for which the amount in controversy for cost reporting periods ended in the same calendar year is, in the aggregate, at least $50,000. Providers that are not part of a CIRP group may not join a CIRP appeal. Providers that are part of CIRP organizations may not join an optional group unless the $50,000 aggregate amount in controversy requirement cannot be met by the CIRP Providers or there are not at least two providers in the CIRP organization that have the issue. 7. 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 "The provider certifies that no other commonly owned providers have, nor will have the same issue pending for the same calendar year." _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 8. Please check below the statement which describes when the issue was added to this appeal and attach the required documentation to support that the issue was timely raised consistent with the checked box. 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. _____ The issue was included in the original appeal request. In order to confirm that this issue was included in the original appeal request, you MUST ATTACH a copy of the original appeal request and/or a copy of Model Form A ­ Individual Appeal Request (including attachment with the statement of issue(s)). _____ The issue was added to the Provider's pending appeal. In order to confirm that this issue was added to the pending appeal, you MUST ATTACH a copy of the letter requesting to add the issue and/or a copy of Model Form C ­ Request to Add Issues Request (including attachment with the statement of issue(s)). 9. Are you the representative for the individual appeal from which the issue is being transferred? _____ YES _____ NO NOTE: If you answered "NO", the Provider/Representative MUST SIGN Section A of the Certification Page and 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. 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: _______________________________________________ Title: _______________________________________________ Signature: _______________________________________________ (Provider/Representative Transferring Issue) Date: _______________________ B. I have reviewed the regulations at 42 C.F.R. § 405.1837, the Board Rules and con