Official Federal Forms
Department Of Health And Human Services (HHS)
Provider Reimbursement Review Board (PRRB)
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Last updated: 2/6/2024
Model Form G Schedule Of Providers
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Description
APPENDIX G: MODEL FORM G – SCHEDULE OF PROVIDERS. This form is is used to document and organize information about the providers involved in a group appeal case. It includes details such as provider numbers, names, locations, appealed periods, MAC information, dates of final determination, dates of appeal request or issue addition, audit adjustment numbers, amounts in controversy, prior case numbers, and dates of direct add or transfer. www.FormsWorkflow.com
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Official Federal Forms/Department Of Health And Human Services (HHS)/Provider Reimbursement Review Board (PRRB)/ -
Official Federal Forms/Department Of Health And Human Services (HHS)/Provider Reimbursement Review Board (PRRB)/
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