Skip to Main Content
Home
Find a Provider
Member Login
Newsroom
Contact
Language
English
Enter Keyword
Search
For Members
Medicaid Plan
Medicare-Medicaid Plan
Health Insurance Marketplace Plan
For Providers
Login
Become a Provider
Enrollment and Updates
Pre-Auth Check
Health Library
Pharmacy
Provider Resources
Provider Training
Bulletins
QI Program
Coronavirus Information
Provider Claims Alerts
Vaccines for Children Program in Michigan
Contact Us
Health Library
COVID-19
Fluvention
Community
Statement of Non-Discrimination
Find a Doctor
For Members
Medicaid Plan
Login
Find a Provider
How to Enroll
Benefits and Services
Member Resources
Find Help
Health Library
Events
Foster Care Resources
Behavioral Health Resources
LGBTQ+ Resources
Medicare-Medicaid Plan
Health Insurance Marketplace Plan
For Providers
Login
Become a Provider
Service Area
Become a Contracted Provider
Enrollment and Updates
Practitioner Demographic Update Form
New Practitioner Enrollment Form
Practitioner Voluntary Termination Form
Pre-Auth Check
Ambetter Pre-Auth
Medicaid Pre-Auth
MMP Pre-Auth
Health Library
Pharmacy
Provider Resources
Manuals, Forms and Resources
Provider Relations Intake Form
Billing and Payments
Clinical & Payment Policies
FAQs
Report Fraud, Waste and Abuse
Medicaid Eligibility Renewal
Community Resources
Provider Training
Annual Training
Provider Education
Provider Orientation
Doula Member Referral Survey
Bulletins
Ongoing Reminders
Community Health Worker (CHW) Bulletin Notification
QI Program
HEDIS
Practice Guidelines
Providing Quality Care
Coronavirus Information
Provider Claims Alerts
Provider CHAMPS Denial Errors
Vaccines for Children Program in Michigan
About Us
Careers
History
Values
Awards and Accreditation
Contact Us
Newsroom
CENTENE SUBSIDIARY MERIDIAN IN MICHIGAN AWARDED MICHIGAN MEDICAID CONTRACTS
Meridian in Michigan and the Centene Foundation Announce $1.1 million Grant to Neighborhood Service Organization
Privacy Policy
Terms & Conditions
Notice of Privacy Practices
Health Library
COVID-19
Fluvention
Community
Statement of Non-Discrimination
SEARCH
MENU
Go!
Home
Find a Provider
Member Login
Newsroom
Contact
Language
English
For Providers
Login
Become a Provider
Service Area
Become a Contracted Provider
Enrollment and Updates
Practitioner Demographic Update Form
New Practitioner Enrollment Form
Practitioner Voluntary Termination Form
Pre-Auth Check
Ambetter Pre-Auth
Medicaid Pre-Auth
MMP Pre-Auth
Health Library
Pharmacy
Provider Resources
Manuals, Forms and Resources
Provider Relations Intake Form
Billing and Payments
Clinical & Payment Policies
FAQs
Report Fraud, Waste and Abuse
Medicaid Eligibility Renewal
Community Resources
Community Health Workers
Provider Training
Annual Training
FWA Attestation
Cultural Competency Attestation
Critical Incidents Attestation
CAHPS Attestation
Provider Education
Provider Orientation
Doula Member Referral Survey
Bulletins
Ongoing Reminders
Community Health Worker (CHW) Bulletin Notification
QI Program
HEDIS
Practice Guidelines
Providing Quality Care
Coronavirus Information
Provider Claims Alerts
Provider CHAMPS Denial Errors
Vaccines for Children Program in Michigan
Become a Contracted Provider
MI Provider Credentialing Application (PDF)
Atypical Provider Credentialing Application (PDF)
Atyplcal provider examples: Doulas, CHW providers
MI Facility Credentialing Application (PDF)
MI Meridian Physician Roster (XLS)
Blank W-9 (PDF)
MI Meridian Disclosure Form (PDF)
Which lines of business do you want to contract with?
required
*
Medicaid
Medicare
Ambetter
MI Health Link
Wellcare Complete
Error:
This field is required.
Are you enrolled in a VFC (vaccine for children) program?
Yes
No
Error:
This field is required.
Specialty
*
Error:
This field is required.
Provider TIN
*
Error:
This field is required.
Group NPI
*
Error:
This field is required.
State License Number
*
Error:
This field is required.
License Issuing State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Error:
This field is required.
State License Expiration Date
*
Error:
This field is required.
Please enter date in (MM/DD/YYYY) format
Name
*
Error:
This field is required.
Legal Name
*
Error:
This field is required.
Contact Name
*
Error:
This field is required.
Contact Phone
*
Error:
This field is required.
Contact Email
*
Error:
This field is required.
Are you submitting for a Provider, Facility, or both?
required
*
Provider
Facility
Provider and Facility
Error:
This field is required.
Upload Completed Provider Credentialing Application
*
Error:
File upload is required.
Items in the trash will be permanently removed after 30 days.
Upload Completed Facility Credentialing Application
*
Error:
File upload is required.
Items in the trash will be permanently removed after 30 days.
Upload Completed W9 Form
*
Error:
File upload is required.
Items in the trash will be permanently removed after 30 days.
Upload Completed MI Meridian Disclosure Form
*
Error:
File upload is required.
Items in the trash will be permanently removed after 30 days.
Upload Completed Physician Roster
Error:
File upload is required.
Items in the trash will be permanently removed after 30 days.
Error:
reCAPTCHA verification failed.
Error:
Please add a Captcha.
Last Updated: 12/04/2024
