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