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 E - REQUEST TO JOIN AN EXISTING GROUP APPEAL: DIRECT APPEAL FROM FINAL DETERMINATION Date of Request: ________________________________ Provider Name: ___________________________________________ Provider Number: _______________________________ Fiscal Year Ended: ______________________________ Intermediary/MAC: _______________________________________ PRRB Group Case Number to which provider is being added: ___________________ Group Case Name: _____________________________________________________________ Date of Final Determination: ________________________ THE GROUP REPRESENTATIVE WILL BE REQUIRED TO SUBMIT A COPY OF THE FINAL DETERMINATION AND SUPPORTING DOCUMENTS ONCE THE GROUP IS COMPLETE. If receipt of Final Determination is more than five days after date of determination, state date received: _______________________ If claiming intermediary/MAC failed to issue a timely Final Determination, state date cost report was sent to intermediary: _______________________ (Include a copy of the cost report certification page and any other evidence to support the date the cost report was filed.) NOTE: Joinder to an existing group must meet the timeliness requirements of 42 C.F.R. § 405.1837(g). Description of Issue: ______________________________________________________________ (Include audit adjustment number if applicable.) Provider Information: Provider Contact/Title: ______________________________________________ Mailing Address: _______________________________________________ _______________________________________________ _______________________________________________ Telephone Number: ____________________ Fax Number: __________________ E-mail Address: _________________________________________ 1 American LegalNet, Inc. www.FormsWorkFlow.com 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.) _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ IF THE GROUP APPEAL THAT YOU ARE REQUESTING TO JOIN 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: A request using this form can only be made to join existing group appeals and group appeals that have been requested previously, but which have not yet been assigned a case number by the Board. If you attempt to join a group case which has not yet been requested to be established, your request will fail, and you will not receive a notice and will be required to meet all requirements for all issues in an 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 added to the group appeal case number _____________. The Provider agrees with request. Printed Name: _________________________________________ (Provider/Rep. Adding Issue) Signature: ______________________________________ Date: ___________________ B. I have reviewed the regulations at 42 C.F.R. § 405.1837, and the Board Rules and consulted with the other representative identified on this form. I have a good faith belief that this addition request meets the single common issue requirement for a group appeal. Signature: ___________________________ (Provider/Rep. Adding Issue) Date: _______________________ C. Signature: ___________________________ (Group Rep.) Date: _____________________ 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 of the group (if known) and the local intermediary/MAC (if different) on this __________day of _______________, 2_____. Certified Mail or Tracking Number: ____________________________ Signature: ___________________________________ Date: _________________ (Group Rep.) 3 American LegalNet, Inc. www.FormsWorkFlow.com