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Provider Intake Form

Note: Completion of this form does not guarantee inclusion into the provider network. It generally takes 20 business days to analyze the form and make a determination if the contract process will commence. Failure to accurately complete the form will significantly extend this processing time

We will outreach to the contact person listed once a review of your data is completed. If you have any questions or are in need of additional information, please contact the Contracting Department at ILJoinOurNetwork@CENTENE.COM

Authorization is required if you need to treat a Meridian Medicaid member prior to being contracted. Our Medical Management department will review the member’s needs with you and issue an Authorization as needed if a contracted provider is not available to provide the services. Medical Management does coordinate with our contracting department when a non-contracted provider receives an Authorization.

Step 1 - Provider Type

Step 2 - Product Interest

Select the products you want to participate in.*

Step 3 - National Identifiers

Step 4 - Illinois Medicaid Number

If applicable to your Product Interest, log into your IMPACT account to verify that your Illinois Medicaid Number is active. If your Illinois Medicaid Number is NOT active, this will result in a denied application for participation in Medicaid products.

Please verify below that your Illinois Medicaid Number is currently active. 

If your Illinois Medicaid Number is NOT active, this will result in a denied application for participation.

Please verify that your Illinois Medicaid Number is currently active.*

If applicable to your Product Interest, provide your Medicare Identifier (Medicare ID)

If your Medicare Identifier is NOT active, this will result in a denied application for participation in Medicare products.

Step 5 - Practice Contact Information

Step 6 - Practice Information

Step 7 - Credentialing Contact Information