Add a New Provider or Term an Existing Provider

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

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

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.

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)

New Provider Roster Upload *

Max File Size: 25 MB

Additional File Upload

Max File Size: 25 MB

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

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone Number *

Date Requested

Comments

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

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

Do you need to term a single Specialist or multiple? * Single Multiple

Specialist NPI # *

Specialist Name

First Name *

Last Name *

Tax ID # * Practitioner will be termed from all locations associated with this TIN.

Group/Facility Name *

Date Term Effective

If other, please indicate reason. *

Update Requested By

First Name *

Last Name *

Contact Email *

Contact Phone Number *

Date Requested

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)

New Provider Roster Upload

Max File Size: 25 MB

New Provider Roster Upload *

Max File Size: 25 MB

First Name *

Last Name *

Contact Email *

Contact Phone Number *

Is this request a PHO affiliation? Yes No

PHO Name

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.

Add a New Provider or Term an Existing Provider

Update Requested By

Primary Care Provider (PCP) Name

Update Requested By

Specialist Name

Update Requested By