Skip to Main Content

Print | Bookmark | Font Size: + | –

AUTOMATED REOPENINGS:

Screen Shot

Form DOS 568PDF (Date of Service Adjustment Request Form) will allow you to change the date of service of line items on a previously processed claim.

Only one claim can be corrected per form; up to 12 line items per claim.

NOTE: In order to complete the form accurately, you must have access to your Remittance Advice (RA). If you download your RA from a billing service or clearinghouse, the line items may be in a different sequence, which will affect the processing on this form. We suggest accessing your RA directly from the myCGS® Web Portal.

Also, to avoid issues with legibility, we encourage you to complete the form online, and then print it.

Automated Reopenings Date of Service Adjustment Request Form Instructions

  • Complete the Header of the form:

    Screen Shot
    • Select the State
    • Enter the date the form is completed in the XX-XX-XXXX format
    • Enter a contact person's name and telephone number
      • NOTE: This information is important should we need to contact you with a question regarding your Reopening request.
  • Complete the Provider Information section:

    Screen Shot
    • Identify the last 5 digits of Tax ID number
    • Enter the Billing PTAN
      • Individual physicians/practitioners who reassign benefits to a group, enter the Group PTAN.
      • Solo physicians/practitioners, enter the Individual PTAN.
    • Enter the Billing NPI
      • Individual physicians/practitioners who reassign benefits to a group, enter the Group NPI.
      • Solo physicians/practitioners, enter the Individual NPI.
  • Complete the Beneficiary Information section:

    Screen Shot
    • Enter the Beneficiary's Name
    • Enter the Beneficiary's Medicare ID
      • To avoid processing delays, please verify that the Medicare ID is correct.
  • Identify the claim information:

    Screen Shot
    • Enter a Date of Service from the claim.
    • Identify a HCPCS/CPT code (procedure code) that corresponds to the date of service.
    • Enter the Internal Control Number (ICN) of the claim, which is located on the RA. 
      • Verify that the ICN is accurate. Incorrect, incomplete, or invalid ICNs will result in increased processing time (up to 60 days).
  • Complete each column of the Adjustment Details section using information from the RA:

    Screen Shot
    • Identify the Line you wish to have corrected. 
      • For example, if the RA shows the claim was submitted with nine line items, and the correction is needed on line six of the claim, enter '6'. (A value of 1-13 may be entered in this field.)
    • Complete the From Date of Service (DOS) New Value field to update the beginning date the service was rendered. Must be in the XX-XX-XXXX format.
    • Complete the To Date of Service (DOS) New Value field to update the end date the service was rendered. Must be in the XX-XX-XXXX format.
      • For example: Original claim submitted with date of service 08/01/19 for CPT code 11042.

        Screen Shot
      The correct date of service for CPT code 11042 is 08/31/19. Complete the Adjustment Details field as:
    Screen Shot

Please pay special attention to the Adjustment Details section. Forms submitted with inaccurate, incomplete, or missing Line and/or New Values may result in increased processing time of up to 60 days.

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved