Form D - Request To Transfer Issue To A Group Appeal - Department Of Health & Human Services - Provider Reimbursement Review Board

Download a blank fillable Form D - Request To Transfer Issue To A Group Appeal - Department Of Health & Human Services - Provider Reimbursement Review Board in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form D - Request To Transfer Issue To A Group Appeal - Department Of Health & Human Services - Provider Reimbursement Review Board with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

DEPARTMENT OF HEALTH & HUMAN SERVICES
PROVIDER REIMBURSEMENT REVIEW BOARD
1508 Woodlawn Drive, Suite 100
Baltimore, MD 21207
Phone: 410-786-2671
Fax: 410-786-5298
MODEL FORM D – REQUEST TO TRANSFER ISSUE TO A GROUP APPEAL
YOU MUST FILE AN ORIGINAL AND 1 COPY OF THIS FORM (MARKED COPY)
Date of Request: _______________________
Prior PRRB Case No(s).: _______________________
(NOTE: You MUST provide full transfer history if issue has resided in more than one case.)
Provider Name: _____________________________________________________
Provider Number: _______________________
Fiscal Year Ended: _______________________
1. Describe the Issue that is being transferred and include the relevant audit adjustment number,
if applicable:
_________________________________________________________________________________
_________________________________________________________________________________
2. Is this the last issue remaining in the individual appeal?
_____ YES
_____ NO
If so, check Yes and the individual case will be closed due to the transfer of the remaining issue.
3. What is the PRRB Group Case Number and name of the group to which the issue is being
transferred?
Group Case No.: _______________________
Group Case Name: _____________________________________________________________
NOTE: If the group appeal to which you are requesting to transfer has not yet been assigned a case
number, please provide the following information OR attach a copy of the group appeal request:
Date of Group Appeal Request:
_______________________________________________
Group Representative’s Name:
_______________________________________________
Group Representative’s Company: _______________________________________________
Proposed Name of Group Appeal: _______________________________________________
NOTE: Transfers using this form can ONLY be made to existing group appeals and to group
appeals that have been requested previously, but which have not yet been assigned a case number by
the Board. If you attempt to transfer an issue to a group case that has not yet been requested to be
established, your transfer request will not be processed and the issue will remain in the individual
appeal.

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Department Of Health & Human Services - Individuals Informed Consent To Non - Therapeutic Sterilization For Medicaid Recipients Department Of Health & Human Services - Individuals Informed Consent To Non - Therapeutic Sterilization For Medicaid Recipients Legal
Form Hcfa 845 - Certificate Of Medical Necessity - U.s. Department Of Health & Human Services Form Hcfa 845 - Certificate Of Medical Necessity - U.s. Department Of Health & Human Services Legal
Form 5 Design Of Pressure Dosing System - Department Of Health & Human Services Form 5 Design Of Pressure Dosing System - Department Of Health & Human Services Legal
Form Ece-cc-10g - Child Care Attendance Sheet - West Virginia Department Of Health & Human Resources Form Ece-cc-10g - Child Care Attendance Sheet - West Virginia Department Of Health & Human Resources Business
Form Pm 101 - Application For Registration As School Audiometrist - California Department Of Health Care Services Form Pm 101 - Application For Registration As School Audiometrist - California Department Of Health Care Services Legal
Form Doh961-135 - Wic Formulas And Foods Prescription Form - Infants Birth To 1st Birthday - Washington Department Of Health Form Doh961-135 - Wic Formulas And Foods Prescription Form - Infants Birth To 1st Birthday - Washington Department Of Health Medical
Notice Of Parental/guardian Consent To A Marriage - Maine Department Of Health And Human Services Notice Of Parental/guardian Consent To A Marriage - Maine Department Of Health And Human Services Legal
Septic Form 2a - General Site Evaluation Data - Department Of Health & Human Services Septic Form 2a - General Site Evaluation Data - Department Of Health & Human Services Legal
Pediatric Hiv Exposure Reporting (pher) - U.s. Department Of Health & Human Services Pediatric Hiv Exposure Reporting (pher) - U.s. Department Of Health & Human Services Legal
State Form 202 - Request To Lease Space - Indiana Department Of Administration State Form 202 - Request To Lease Space - Indiana Department Of Administration Legal

Related Categories

Parent category: Legal
Download
Go
Page of 4