Submit Multiple Request Types

Choose All Applicable Networks required*

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

If 5 or more provider updates are needed, please download the Meridian Roster Template and attach it in the upload field. All required roster fields must be completed.

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

Delegated Group?
Is this for a PHO agreement? *

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
  • If submitting a new facility or clinic, a credentialing application (PDF) will be required, along with the documents referenced on the last page of the application.

This form will send your message to Meridian as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with Meridian through email, you accept associated risks. Meridian does not accept responsibility or liability for any loss or damage arising from the use of email. To ensure the safety of your protected health information (PHI), please send us a message through the Secure Member or Provider portal.