Manuals, Forms and Resources
Provider Manual
The Provider Manual has everything you need to know about member benefits, coverage, and provider guidelines. Click the link below to view or save a copy.
Documents and Forms
- 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)
- Acute and Chronic Opioid Therapy Policy (PDF)
- Adakevo (PDF)
- Betamethasone Dipropinate (Sernivo) (PDF)
- Bevacizumab (Avastin, Mvasi, Zirabev) (PDF)
- Calcipotriene-Betamethasone Dipropionate Foam (Enstilar) (PDF)
- Certolizumba (Cimzia) (PDF)
- Clozapine (Fazaclo) (PDF)
- Colesevelam (Welchol) (PDF)
- Contimuous Glucose Monitor Criteria (Dexcom) (PDF)
- Dermatology Class Criteria (PDF)
- Eculizumab (PDF)
- Efinaconazole (Jublia) (PDF)
- Elagolix (Orilissa), Elagolix/Estradiol/Norethinedrone (Oriahnn) (PDF)
- Endari (PDF)
- Esketamine (Spravato) (PDF)
- Farxiga (PDF)
- Gastrointestinal Agents (PDF)
- Immune Globulins (PDF)
- Insulin Delivery Systems (V-Go, Omnipod, InPen) (PDF)
- Isturisa (PDF)
- Lasmiditan (Reyvow) (PDF)
- Linezolid (Zyvox) (PDF)
- Migraine Prophylaxis – Preferred Agents (PDF)
- Mometasone Furoate (Sinuva) (PDF)
- Non-Preferred Blood Glucose Monitors/Test Strips (PDF)
- Olanzapine Long-Acting Injection (Zyprexa Relprevv) (PDF)
- Oxbryta (PDF)
- Pegfilgrastim (Neulasta), Pegfilgrastim-jmdb (Fulphila), Pegfilgrastim-cbqv (Udenyca), Pegfilgrastim-bmez (Ziextenzo), Pegfilgrastin-apgf (Nyvepria) (PDF)
- Propranolol HCl Oral Solution (Hemangeol) (PDF)
- Request for Exceptions to the Formulary (PDF)
- Request for Non-Preferred Formulary Agents (PDF)
- Risperidone Long-Acting Injection (Perseris, Risperdal Consta) (PDF)
- Rituximab (Rituxan), Rituximab-pvvr (Ruxience), Rituximab-abbs (Truxima), Rituximab-Hyaluronidase (Rituxan Hycela) (PDF)
- Rivastigmine (Exelon) (PDF)
- Safinamide (Xadago) (PDF)
- Sunosi (PDF)
- Suvorexant (Belsomra) (PDF)
- Tepezza (PDF)
- Trastuzumab/Biosimilars, Trastuzumab-Hyaluronidase (PDF)
- Ubrogepant (Ubrelvy) (PDF)
- Vyepti (PDF)
- Wakix (PDF)
- Meridian Billing Manual
- FORM144 IL Crossover Claim Resolution (PDF)
- Billing Guidelines for EAPG Pricing (PDF)
- C32 Provider Billing Education Guidance (PDF)
- CMHC Billing Guidelines (PDF)
- D01 Duplicate Claim Submissions Guidance (PDF)
- DASA Billing Guidelines (PDF)
- Electronic Funds Transfer Form (PDF)
- Encounter Billing Education (PDF)
- Encounter Clinic Billing FAQs (PDF)
- Guidelines for Custodial and Supportive Living Authorizations (PDF)
- HFS Managed Care Billing and Encounter Guidelines - DASA (PDF)
- Hospice Routine Home Care and Continuous Home Care (PDF)
- IAMHP Comprehensive Billing Manual (PDF)
- IAMHP Memo to All Health Plans (PDF)
- Illinois Medicaid Fee Schedule
- LTC Billing Guidelines (PDF)
- Medical Assistance Program (MAP) Guidelines (PDF)
- MTM Transportation Billing Guidelines Review (PDF)
- Patient Credit File (PDF)
- Pharmaceutical Labelers with Signed Rebate Agreements (PDF)
- Physician Assistant Billing Guidelines (PDF)
- Renal Dialysis Value Code Requirements (PDF)
- Request for Provider Dispute Form
- Timely Submission of Encounter Data by Medicare-Medicaid Plans (MMPs) to CMS (PDF)
- IL APL Notice (PDF)
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)
- 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