Model Form A-Individual Appeal Request {A}

APPENDIX A: MODEL FORM A – INDIVIDUAL APPEAL REQUEST OR SUPPLEMENTAL APPEAL FROM ADDITIONAL FINAL DETERMINATION. This form is used for filing an appeal with the Provider Reimbursement Review Board (PRRB) under Medicare. The form requires the selection of the type of appeal request, followed by the submission of general provider information, parent organization information (if applicable), Medicare Administrative Contractor (MAC) information, representative information, and details regarding the determination being appealed. Depending on the type of determination being appealed (e.g., Notice of Program Reimbursement, Revised NPR, Exception Determination, etc.), the form requests specific information and supporting documentation. Additionally, if there are multiple issues being appealed, each issue must be separately detailed with supporting documentation. The form also includes 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