Contract Request Form

Note: Completion of this form does not guarantee inclusion into the provider network. It generally takes 30 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 submit a request via our provider relations intake form.

Authorization is required if you need to treat a Meridian 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.

Provider Credentialing Rights

During the credentialing process, Meridian obtains information from various sources to evaluate your application. Ensuring the accuracy of this information is key, so please review and provide any corrected information as soon as possible. You also have the right to review the status of your credentialing or recredentialing application at any time by calling your health plan Provider Relations Representative.