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.

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

• Illinois Regulatory Requirements Manual (PDF)
• Ohio 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)