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Form POS 419PDF (Reopenings Place of Service Adjustment Request Form) will allow you to request simple correction to replace the place of service (POS) code on a line item of 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 Place 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
    • 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 the Adjustment Details section:

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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.)
    • Identify the New Value Place of Service code in the second column.
      • For help identifying valid two-character POS codes, refer to the front cover of a current CPT Manual.

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

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