Join Our Network

Note: Completion of this form does not guarantee inclusion into the provider network. It generally takes 20 business days to analyze the form and make a determination if the contract process will commence. Failure to accurately complete the form will significantly extend this processing time.

We will outreach to the contact person listed once a review of your data is completed. If you have any questions or are in need of additional information, please contact the Contracting Department at ILJoinOurNetwork@CENTENE.COM.

Authorization is required if you need to treat a Meridian Medicare-Medicaid member prior to being contracted. Our Medical Management department will review the member’s needs with you and issue an Authorization as needed if a contracted provider is not available to provide the services. Medical Management does coordinate with our contracting department when a non-contracted provider receives an Authorization.

Step 1 - Provider Type

Select your provider type *

Ancillary Clinic FQHC Group Practice Hospital Individual Provider RHC

Step 2 - Product Intrest

Select the product you want to participate in. *

Meridian Medicaid Plan and YouthCare Meridian Medicare-Medicaid Plan Ambetter Wellcare Wellcare Complete

Step 3 - National Identifiers

Group NPI *

Tax ID Number *

Step 4 - Illinois Medicaid Number

If applicable to your Product Interest, log into your IMPACT account to verify that your Illinois Medicaid Number is active. If your Illinois Medicaid Number is NOT active, this will result in a denied application for participation in Medicaid products.

Illinois Medicaid Number *

Please verify below that your Illinois Medicaid Number is currently active.

If your Illinois Medicaid Number is NOT active, this will result in a denied application for participation.

I verify that my Illinois Medicaid Number is currently active.

If applicable to your Product Interest, provide your Medicare Identifier (Medicare ID)

If your Medicare Identifier is NOT active, this will result in a denied application for participation in Medicare products.

Step 5 - Practice Contact Information

Practice Name *

Primary Address *

City *

State *

Zip Code *

County *

Primary Phone Number *

Step 6 - Practice Information

Applying as: *

Specialist Primary Care Provider Other

Is this your primary specialty? *

Yes No

Hospital with Admitting Privileges* To select multiple hospitals, hold down the "Ctrl" button when making your selections.

Step 7 - Credentialing Contact Information

Name *

Phone *

Fax *

Email *

Please upload your completed W9 form.

Join Our Network

Step 4 - Illinois Medicaid Number

If applicable to your Product Interest, log into your IMPACT account to verify that your Illinois Medicaid Number is active. If your Illinois Medicaid Number is NOT active, this will result in a denied application for participation in Medicaid products.

Step 8 - W9 Form