Model Form E-Request To Join An Existing Group Appeal {E}

APPENDIX E: MODEL FORM E – REQUEST TO DIRECTLY ADD PROVIDER TO GROUP. This form is used for appealing Medicare reimbursement determinations through the Provider Reimbursement Review Board (PRRB). It allows a provider to join an existing group appeal directly, providing necessary information about the provider, the appeal issue, and the determination being appealed. This form is part of the PRRB's electronic filing system and can be accessed through OH CDMS. It collects essential details such as provider information, representation, determination type, issue title, and supporting documentation. Additionally, it includes certifications ensuring compliance with PRRB regulations and confirming authorization to submit the appeal on behalf of the listed www.FormsWorkflow.com