Model Form D-Request To Transfer Issue To A Group Appeal {D}

APPENDIX D: MODEL FORM D – REQUEST TO TRANSFER ISSUE. This form is used for submitting a request to transfer an issue from an individual case to a group case in appeals processed by the Provider Reimbursement Review Board (PRRB) under Medicare. The form begins with the identification of both the individual case (including case number and name) and the group case (including case number and name). If filing the transfer electronically, representation letter for the group appeal needs to be attached. Following the transfer information, if the request is being filed in hard copy, additional details about the final determination type, fiscal year end date, date of final determination under appeal, MAC code, MAC name, issue title, protested item on the filed cost report, audit adjustment number, and amount in controversy are required. A complete copy of the initial appeal request also needs to be attached in hard copy filings. After providing the necessary information, there are certifications to ensure compliance with PRRB regulations. These certifications confirm that the issue is not pending in any other appeal for the same period and provider, and that the transfer request meets the single common issue requirement for a group appeal (if applicable). Additionally, if the transfer is for an optional group, it certifies that there are no other related providers with pending requests for a Board hearing on the same issue for a cost reporting period ending in the same calendar year. www.FormsWorkflow.com.