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What is your relation to Vālenz?

Your email address

Subject

What is your request about?

Admission Type

Submitter's Name

Phone Number

Where are you submitting from?

Member Name

Reason

TPA, Health Plan or Payer Name

Inpatient Setting

Bed Level

Service Type

DME Type

Dollar Amount

Dollar Amount of DME Request

Level of Injection

Policy Holder Name

The name of the policy holder this request is about

Policy Holder DOB

The DOB of the policy holder this request is about

Member ID - Alpha

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 Member ID

Numeric Portion of your Member ID found on your insurance card

Member ID

Member ID found on your insurance card

Relationship to Insured

Patient Name

Patient Date of Birth

Patient Address

Street Address, City, State, Zip

Patient Phone Number

Member Employer or Insurance Group

Group ID

Requester Name

Requester Email

Physician Fax Number

Requester Phone Number

Physician Name

The name of the physician rendering the services

Physician Address

Physician Phone Number

Physician Fax Number

Physician Tax ID

Physician NPI

Facility Name

The facility name where these services are being provided

Facility Address

Facility Tax ID

Facility Phone Number

Facility Fax Number

Date of Service

Enter date of service for the procedure

Total Billed Charges

Procedure Code

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

Diagnosis Code (ICD 10)

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

Precertification disclaimer

You understand precertification does not guarantee payment or coverage

Benefit Disclaimer

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

Eligibility Disclaimer

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

Did you remember to attach the clinical?

Are you submitting multiple updates?

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.

Change Type

Provider Name

Provider Specialty

Contact Person Name

Contact Person Email Address

Change Effective Date

Provider Degree Type

Provider Individual NPI

Provider Gender

Practice Name

Group Tax ID

Tax ID claims will be submitted under

Group NPI Number

Primary Location

Please provide the complete Primary Address

Primary Location Phone Number

Primary Location Fax Number

Additional Location(s)

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

Affiliated Hospitals

Please list all hospitals this provider has privileges

Location Phone Number

Location Fax Number

Number of Practitioners

How many practitioners are in your group?

Number of Locations

How many locations does your group have?

Multiple Update Acknowledgement

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

Required Document -W9

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

Description

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

Reason for referral

Enter the reason for the referral.

Explanation of Benefits (EOB)

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

Billed Charge

Attachments

Add file or drop files here

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