Submit a request

If yes, please retrieve the required report here: and attach your file at the bottom of the page.

If yes, please retrieve the required report here: and attach your file at the bottom of the page.

By checking this box, I certify I have completed and attached the Void Requests form.

If any of the below fields are unavailable, please place N/A in the entry

Name of your Organization

By Checking this box, I certify I have completed and attached the Refund Request form.

Please enter your Vālenz provided invoice number

The name of the member this request is about

The DOB of the member this request is about

Member ID found on your insurance card

Geo Access Reports identify (by member zip codes) the number of providers and facilities within a mile radius (as requested). Please retrieve the report requirements here: and attach your file at the bottom of the page.

Disruption Report identifies (by tax identification number) if a specific provider is in-network. Please retrieve the report requirements here: and attach your file at the bottom of the page.

Claims Review/Savings Analysis Review - utilizing clients existing paid claims data (typically 6 months to 1 year), this reporting offers a comparison from a requested PPO network. Please retrieve the report requirements here: and attach your file at the bottom of the page.

A Valenz DSA (Detailed Savings Analysis) is designed to represent the manner in which claims and charges would be repriced with our out-of-network cost reduction solutions. Isolated by TIN, POS, CPT, Bill Type, PAR Designation and other unique claim characteristics, Valenz reviews the data and selects the solution that will yield the best results for each claim. Those results are then rolled-up into corresponding repricing methodologies and Valenz calculates the savings results to be expected. Please retrieve the report requirements here: and attach your file at the bottom of the page.

Savings reports offer a summary page for each client group. Additionally, a rab is available for review of claims data at the group level. This report can be generated at will and for any time period, typically within a matter of minutes. Please retrieve the report requirements here: and attach your file at the bottom of the page.

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

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

Enter date of service for the procedure

The name of the physician rendering the services

Username you use to login to the system, not your e-mail address. For EPStaffCheck, typically follows the format of: ABCDef

If other, please list in the Description below

Select Refund Reason

Include Company Name and Full Address

Include Company Name and Full Address

Date batch report was ran

Please use Attachment(s) section below for any screenshots you may have

Date claim was submitted to ClaimScrub

Tax ID claims will be submitted under

Please list one or more counties or states that you would like included in the directory

Enter the correct number of units

Enter the dollar amount of the claim

The facility name where these services are being provided

Enter the reason for the referral.

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

Request priority

Add file or drop files here