See all
Member DocumentsNeed Help? Call Us.
1-866-946-4458
(TTY: 711)
Phone: 1-866-946-4458 | Fax: 1-866-946-4458
Date:
Member Information
Member Last Name:
Member First Name:
Date of Birth:
Member Identification Number:
Provider/Facility Information
Contact Name:
Phone Number (with area code):
Email Address:
Provider First and Last Name: (as listed on Evidence of Payment “EOP”)
Facility/Group Affiliation: (as listed on Evidence of Payment “EOP”)
Street Address:
City, State, Zip Code:
NPI Number:
Tax ID Number:
Reason for Request
Date of Service:
Claim #:
Total Charges:
Expected Amount:
Denied - “Exceeds Timely Filing”
Denied requesting additional information
Denied - “Coordination of Benefits”
Resubmission of corrected claim - requires the CORRECTED be submitted electronically
Previously adjudicated but applied incorrect rate resulting in over/underpayment
Denied for “no authorization”
Other (provide details below)
Comments – Reason for Dispute
Please include the following: (1) a copy of the initial claim (2) a copy of the EOP (3) all other documents supporting the request for dispute and mail to:
ATTN: Provider Disputes
Zing Health Plan, Inc.Zing
303 West Madison Street, Suite 800
Chicago, IL 60606