Submit a request

Dollar Amount of DME Request

The name of the member this request is about

The DOB of the member this request is about

Please select the Alphabetic Portion of your Member ID found on your insurance card. This piece must be entered separately from the numeric portion.

Numeric Portion of your Member ID found on your insurance card

Member ID found on your insurance card

The name of the physician rendering the services

The facility name where these services are being provided

Facility Fax Number

Enter date of service for the procedure

Enter procedure code (CPT/HCPS code) You may enter multiple codes using a comma to separate.

Enter the diagnosis code (ICD10 code) You may enter multiple codes using a comma to separate.

You understand precertification does not guarantee payment or coverage

You understand Precertification only identifies medical necessity and does not identify benefits.

You have/will call the benefits/eligibility number on the ID card to verify coverage.

If yes, please retrieve the required report here: https://support.valenzhealth.com/hc/en-us/articles/1500000241681-How-do-I-submit-provider-and-or-group-updates- and attach your file at the bottom of the page.

Tax ID claims will be submitted under

Please provide the complete Primary Address

Please list the complete address of the additional location(s)

Please list all hospitals this provider has privileges

How many practitioners are in your group?

How many locations does your group have?

By Checking this box I certify I have completed and attached the completed Valenz Access Roster

By Checking this box I certify I have attached the group W9 form.

Please enter the details of your request. A member of our support staff will respond as soon as possible.

Enter the reason for the referral.

By Checking this box I certify I have attached the EOB related to my appeal submission.

Add file or drop files here