Official Federal Forms > Department Of Health And Human Services (HHS) > Provider Reimbursement Review Board (PRRB)
Model Form F Proposed Joint Scheduling Order F - Official Federal Forms
| Model Form F Proposed Joint Scheduling Order Form. This is a national form and can be used in Provider Reimbursement Review Board (PRRB) Department Of Health And Human Services (HHS) . |
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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 F PROPOSED JOINT SCHEDULING ORDER Date of Request: _______________________ PRRB Case Number: _______________________ Provider/Group Name: _____________________________________________________ Provider/Group FYE: _______________________ Provider No(s).: _____________________________________________________ Intermediary/MAC: _____________________________________________________ A. Resolved Issues Under a TAB LABELED 1, identify appealed issues resolved by the parties. B. Conditionally Resolved Issues Under a TAB LABELED 2, identify issues on which conditional resolution has been reached. Include for each conditionally resolved claim: 1. A brief statement of the issue. 2. A description of the conditions on which resolution is based, including dates, actions, and audit methodologies required by the parties. [Example: Issue 1 is whether the Provider's travel expenses were adequately documented-The issue is conditionally resolved based on the Provider's representation that it will furnish the September 2004 travel logs by June 1, 2008.] C. Unresolved Issues Under a TAB LABELED 3, identify issues that have not been resolved. Include for each unresolved issue: 1. A brief statement of the issue. 2. A brief statement of the material facts and indicate whether they are disputed. 3. For claims that cannot be resolved because of a question of law, briefly state each party's legal position and the authorities relied upon. 4. Listing of documentation exchanged to date. 5. If the parties expect the case to require discovery, or a voluntary exchange and analysis of data, create a detailed timetable/schedule for that exchange. This schedule will supersede the timelines in the regulations as permitted by 42 C.F.R. 405.1853(e)(3)). American LegalNet, Inc. www.FormsWorkFlow.com [Example: Unresolved Issue 1 is Medicaid Eligible Days January 1, 20xx Provider will submit to Intermediary an updated Medicaid eligible days listing. February 1, 20xx Intermediary will have sampled listing and given sampled items to Provider with request for supporting documentation. March 1, 20xx Provider will supply all documentation requested by the Intermediary in support of the sample. March 15, 20xx - Intermediary will have reviewed documentation submitted by Provider in support of sample and will inform Provider of audit findings. Additional documentation requests will be provided by this date. April 1, 20xx Provider will respond to audit findings with any additional documentation. April 15, 20xx Intermediary will submit finalized adjustments to Provider. May 1, 20xx Final Administrative Resolution will be drafted or parties will inform PRRB that an Administrative Resolution cannot be reached. Also include a timetable for the following actions for any unresolved matters. You may state the date (month/day/year) or express the date as the number of days from an event (e.g., prior to hearing): Provider's preliminary position paper Intermediary's preliminary position paper Exhibit exchange deadline Witness list deadline Subpoena requests] NOTE: Once the JSO is approved by the Board, the parties may modify JSO deadlines only by their signed, written agreement. An e-mail confirmation or faxed signature is sufficient to signify agreement. A modification of the hearing date requires Board approval. The Board will consider the agreed upon dates as deadlines and failure to meet the deadlines, upon objection, may result in Board action subject to 42 C.F.R. § 405.1868, including, but not limited to, excluding evidence or dismissal. D. Identify a mutually agreed upon month and year for hearing: ___________________________ This date should not be less than 180 days from the last documentation deadline set in C.5 above. (The Board typically will not schedule a case less than a year after the filing of the appeal unless a special circumstance exists; however, the Board will consider accelerated hearing requests (See Rule 31) at any time). American LegalNet, Inc. www.FormsWorkFlow.com E. Signatures The undersigned have agreed that this document accurately identifies all issues in Case No. _________________ and the parties have agreed upon the deadlines set forth in this document. The parties understand that the Board's issuance of a hearing date on or after the requested hearing date in D. above will constitute the Board's acceptance of all other proposed JSO deadlines. All other deadlines and evidence cut offs will be controlled by the parties' JSO unless the Board advises otherwise. The parties must meet all deadlines within the JSO, including agreed upon written modifications, even if the hearing is scheduled later than requested. Provider Representative: Intermediary Representative: _____________________________________ Print Name _____________________________________ Title/Organization _____________________________________ Signature _____________________________________ Date _____________________________________ Print Name _____________________________________ Title/Organization _____________________________________ Signature _____________________________________ Date American LegalNet, Inc. www.FormsWorkFlow.com
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