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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:

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    • 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:

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    • Enter the Provider’s Name
    • 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.
  • Complete the Beneficiary Information section:

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    • 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:

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    • 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:

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    • 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.

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

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