Model Form B-Group Appeal Request {B}

APPENDIX B: MODEL FORM B – GROUP APPEAL REQUEST. This form is used for filing a group appeal with the Provider Reimbursement Review Board (PRRB) under Medicare. The form is specifically for an "Optional Group" or a "Common Issue Related Party (CIRP) Group." The form requests issue information, where the title of the issue being appealed is provided along with any attachments of issue statements. The form also inquires if the appeal is based on a Federal Register Notice and requires details regarding the lead Medicare Administrative Contractor (MAC). Following this, the form asks for information about group participants, including transfer requests and direct add requests. Representation letters for each provider must be attached. Finally, there are certifications to ensure compliance with PRRB statutes, regulations, and rules, as well as confirmation of the appeal's validity and authorization by the individual submitting the appeal. www.FormsWorkflow.com