Manuals, Forms and Resources

• Meridian Medicaid Authorization Lookup
• PA Codes - Dental Services (PDF)
• Authorization Referral Form
• Acknowledgment of Hysterectomy Form (PDF)
• Bariatric Preoperative Evaluation Checklist (PDF)
• Care Coordination/Complex Case Management Referral Form (PDF)
• Consent to Sterilization Form (PDF)
• Data Exchange Request Form (PDF)
• Electronic Medical Request Form (PDF)
• HealthHelp and eviCore Provider Notification (PDF)
• Mobile Crisis Response FAQs (PDF)
• Mobile Crisis Response Provider Reference Guide (PDF)
• Primary Care Provider Reassignment Form (PDF)
• IL Medicaid Provider Referral Grid (PDF)
• Provider Referral to Care Coordination & Complex Care Mgmt Form (PDF)
• Post-Service Medical Necessity Appeals (PDF)

• Medication Prior Authorization Request Form (PDF)
• Member Request for Reimbursement Form (PDF)
• Online Pharmacy Prior Authorization (PA)

Additional pharmacy information.

Please consult the provider manual. Additional billing information can be found in the Illinois Association of Medicaid Health Plans (IAMHP) Comprehensive Billing Manual.

Mandatory Training Attestation (PDF)

• Agreement for Participation in MAP (PDF)
• Instructions for Enrollment into MAP (PDF)
• MAP Provider Enrollment Form (PDF)

• Mental Health Provider Enrollment Application (PDF)
• Mental Health Provider Instructions for MAP Enrollment (PDF)

• Adolescent Immunization Schedule
• Adult Immunization Schedule
• HEDIS® Quick Reference Guide
• Pediatric Immunization Schedule

MeridianHealth offers vision benefits to members enrolled in specific health plans.

View the Vision Benefits Chart (PDF) available to members in each of our Illinois health plans.

• Instructions – Ordering Vision Hardware from Classic Optical Laboratories (PDF) (for Medicaid and Medicare-Medicaid Alignment Initiative (MMAI) members)
  • NOTE: Please DO NOT contact Classic Optical about any prior authorizations
• Order Form – Classic Optical Laboratories (PDF)
• Instructions – Ordering Vision Hardware from JAK Optical Laboratories (PDF) (for Medicaid and Medicare-Medicaid Alignment Initiative (MMAI) members)
  • NOTE: Please DO NOT contact JAK about any prior authorizations
• Order Form – JAK Optical Laboratories (PDF)

• CAQH Credentialing Application
• Illinois Credentialing Application (PDF)
• Universal Roster

• 1 to 4 Weeks (PDF)
• 2 Month (PDF)
• 4 Month (PDF)
• 6 Month (PDF)
• 9 Month (PDF)
• 12 Month (PDF)
• 15 Month (PDF)
• 18 Month (PDF)
• 2 Year (PDF)
• 3 Year (PDF)
• 4 Year (PDF)
• 5 Year (PDF)
• 6 Year (PDF)
• 7-8 Year (PDF)
• 9-10 Year (PDF)
• 11-17 Year (PDF)
• Recommendations for Preventive Pediatric Health Care (PDF)
• EPSDT Toolkit (PDF)

• Illinois Regulatory Requirements Manual (PDF)

• Illinois Subcontractor Regulatory Requirements Manual (PDF)

• Meridian's Advance Directives Information (PDF)
• Directivas Anticipadas información de Meridian (PDF)
• Living Will (PDF)
• Power of Attorney for Health Care (PDF)
• Resources for Illinois Advance Directives
• Testamento Vital (PDF)

• Illinois Client Enrollment Services
• Illinois Dept of Healthcare and Family Services
• Medicare Provider - Supplier Enrollment

• Critical Incident and Significant Event Intake Form (PDF)
• Meridian Critical Incident Provider Education (PPT)

• Applied Behavioral Analysis (ABA) Outpatient Treatment Request Form (PDF)
• Applied Behavioral Analysis Outpatient Treatment Request Checklist (PDF)
• Incomplete Provider Information (PDF)
• Behavioral Health Discharge Transition of Care Form (PDF)
• METS Provider Flyer (PDF)
• METS FAQ Sheet (PDF)