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Model Form F - (2013) PDF, 43KB

Model Form F - (2013) PDF, 43KB-2025

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The document is a proposed joint scheduling order (JSO) from the Department of Health & Human Services' Provider Reimbursement Review Board. It outlines the process for resolving issues related to provider reimbursements, including sections for resolved, conditionally resolved, and unresolved issues. The JSO requires identification of specific claims, conditions for resolution, timelines for documentation exchange, and mutual agreement on hearing dates. Signatures from both provider and intermediary representatives are required to confirm agreement on the document's contents and deadlines.

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Click ‘Get Form’ to open the Model Form F - (2013) PDF in the editor.
Begin by entering the 'Date of Request' and 'PRRB Case Number' at the top of the form. These fields are essential for tracking your submission.
Fill in the 'Provider/Group Name' and 'Provider/Group FYE'. Ensure accuracy as this information identifies your organization.
In the 'Intermediary/MAC' section, specify the relevant intermediary or Medicare Administrative Contractor involved in your case.
Navigate to TAB LABELED 1 to list any resolved issues. Clearly state each issue that has been settled between parties.
Under TAB LABELED 2, document conditionally resolved issues. Include a brief statement of each issue along with conditions for resolution.
For unresolved issues under TAB LABELED 3, provide detailed statements including material facts and legal positions if applicable.
Finally, ensure all signatures are completed at the bottom of the form before saving or exporting your finalized document.

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Model Form F - (2013) PDF, 43KB-2025

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