Submit Multiple Request Types

Choose All Applicable Networks * Ambetter Meridian Medicaid YouthCare Wellcare Meridian Dual Align (HMO D-SNP) Wellcare

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

First Name *

Last Name *

Contact Email *

Contact Phone Number *

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? Yes No

Delegated Group Name? *

Is this for a PHO agreement? * Yes No

PHO Name? *

How many total updates, terms, or adds does your request contains? *

1. Providers must be IMPACT approved for Medicaid and YouthCare, and Medicaid numbers must be supplied.

2. If you are enrolling for DSNP, it is required for certain provider types* to be IMPACT approved. For all other provider types, if you are not active and approved with IMPACT, standard credentialing applies. Please see #3 below for instructions.

3. Prior to Ambetter, Medicare, and some DSNP 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.

*The below list of provider types MUST be approved and active with IMPACT to enroll in DSNP.

Specialty	HFS Provider Type
Home and Community Based Service (HCBS)	PT 90-98
Community Mental Health Centers (CMHC)	PT 36
Substance Use Prevention & Recovery (SUPR)	PT 75
Certified Community Behavioral Health Clinics (CCHBC)	PT 113
Behavioral Health Center (BHC)	PT 27
Supportive Living Facilities (SLF)	PT 28
Specialized Mental Health Rehabilitation Facilities (SMRFH)	PT 38
Hospice (billing rev code 658)	PT 39
Nursing Facilities (providing custodial care)	PT 33

New Provider Roster Upload *

Max File Size: 25 MB

Comments

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.