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Demographic Change

What do you want to do? *

Service Location Address

Update Requested By

Practitioner Current Name

Practitioner New Name

Update Requested By

Practitioner Name

Update Requested By

Practitioner Name

Service Location Address

New Provider Office Hours

Update Requested By

Service Location Address

Service Location Office Hours

Update Requested By

Choose All Applicable Networks required*
Select subject *

If submitting for specific WellCare product(s), indicate applicable products in Comments section

If multiple practitioners' provider updates are needed, please download the Meridian Roster Template and attach it in the upload field. All roster fields are required.

Meridian Roster Template (Excel)
(Roster template revised 02/04/2022)

1. Providers must be IMPACT approved for any Medicaid, YouthCare, or Dual product, and Medicaid numbers must be supplied

2. Prior to Ambetter and Medicare submissions:

  • Validate CAQH is current and accessible to the health plan for all practitioners
  • NOTE: CMS does not allow more than 20 locations per practitioner

Update Requested By

 

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