Model Form C-Request To Add Issue(s) To An Individual Appeal {C}

APPENDIX C: MODEL FORM C – REQUEST TO ADD ISSUE. This form is used for submitting a request to add an issue to an existing appeal with the Provider Reimbursement Review Board (PRRB) under Medicare. The form begins with identifying information such as the case number and name, followed by details related to the issue being added. This includes information about the final determination type, date of the final determination under appeal, issue title, and any relevant attachments such as an issue statement, protested item support, audit adjustment number, and calculation support. There are certifications to ensure compliance with PRRB statutes, regulations, and rules. These certifications confirm that the issue is not pending in any other appeal for the same period and provider, and that the individual submitting the request is authorized to do so on behalf of the listed provider. www.FormsWorkflow.com