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 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: _____________________________________________________ 1. 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. 2. Date of Notice of Final/Revised Determination: _______________________ Type of Final Determination: _____ Notice of Program Reimbursement (NPR) (Check one) _____ Revised NPR _____ Exception Determination _____ Federal Register Notice _____ Failure to Issue a Timely Determination _____ Other (Specify: _________________________________) American LegalNet, Inc. www.FormsWorkFlow.com YOU MUST ATTACH A COPY OF THE FINAL/REVISED DETERMINATION UNDER A TAB LABELED 1. * If appealing from a Revised NPR, you MUST also provide copies of: (1) the NPR immediately preceding the Revised NPR under appeal, (2) the Reopening Request that preceded the Revised NPR (if applicable), (3) the Reopening Notice issued by the Intermediary, (4) the Revised NPR workpapers (for the issue(s) under appeal), and (5) any applicable cost report worksheets (e.g., Worksheet E). See Rule 7.1. * If claiming Intermediary/MAC failed to issue a timely Final Determination, state the date the cost report was sent to the Intermediary: _______________________. You MUST also include copies of: (1) the certification page of the perfected or amended cost report, (2) the certified mail receipt evidencing the Intermediary's receipt of the as-filed and any amended cost reports, (3) the Intermediary's letter or e-mail acknowledging receipt of the as-filed and any amended cost reports, (4) evidence of the Intermediary's acceptance or rejection of the as-filed and any amended cost reports, and (5) the documentation described in Rule 7.2, as relevant, if the issue(s) being appealed involves one or more self-disallowed items. See Rule 7.4. * If receipt of Final/Revised Determination is more than five days after date of determination, state date received: _______________________. You MUST also include a copy of documentation to support the actual date of receipt. NOTE: Joinder to an existing group must meet the timeliness requirements of 42 C.F.R. § 405.1837(g). 3. Description of Issue (include the relevant audit adjustment number, if applicable): _________________________________________________________________________________ _________________________________________________________________________________ 4. Provider Information: Provider Name: Provider Contact/Title: Provider Address: ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ Provider Telephone Number: Provider Fax Number: E-mail Address: American LegalNet, Inc. www.FormsWorkFlow.com 5. Is this Provider commonly owned or controlled? _____ 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: ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ 6. Is the group a mandatory Common Issue Related Party (CIRP) group appeal? _____ YES _____ NO 7. 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. 8. 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." _________________________________________________________________________________ _________________________________________________________________________________ __________________________