Skip to Main Content
Home
Find a Doctor
Member Login
Newsroom
Contact
Enter keyword for site search.
Search
Contrast
On
Off
a
a
a
language
English
For Members
Health Insurance Marketplace Plan
Medicaid Plan
Medicare-Medicaid 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
Contact Us
Health Library
Disease Management
Preventive Health
COVID-19
Fluvention
SEARCH
MENU
search
Go!
About Us
Careers
Find a Doctor
For Members
Health Insurance Marketplace Plan
Medicaid Plan
Login
Find a Provider
How to Enroll
Why Meridian?
Service Area
Benefits and Services
Rewards Program
Health Risk Assessment
Get the Most from Your Coverage
Pharmacy
Disease Management
Smart Start for Your Baby
CSHCS
Prior Authorization
Member Resources
Medicaid Eligibility Renewal
Helpful Links
Member Handbooks and Forms
Newsletters
FAQs
Quality Improvement Program
Reporting Fraud, Waste and Abuse
Interoperability and Patient Access
Community Resources
Health Library
Medicare-Medicaid Plan
For Providers
Login
Become a Provider
Service Area
Enrollment and Updates
Become a Contracted Provider
Contracted Enrollment Request Practitioner
Demographic Update Tool
Contracted Enrollment Request
Provider Effective Date Policy
Definition of Enrollment, Credentialing, and Contracting
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 Pieces
Provider Orientation
Bulletins
QI Program
HEDIS
Practice Guidelines
Providing Quality Care
Coronavirus Information
Provider Claims Alerts
Contact Us
Newsroom
Meridian Celebrates 25 Years of Serving Michigan
Meridian of Michigan Appoints Patricia Graham as CEO
Privacy Policy
Terms & Conditions
Notice of Privacy Practices
Health Library
Disease Management
Preventive Health
COVID-19
Fluvention
redirect
Quality Program
Quality
language
English
Home
Find a Doctor
Member Login
Newsroom
Contact
For Providers
Login
Become a Provider
Service Area
Enrollment and Updates
Become a Contracted Provider
Contracted Enrollment Request Practitioner
Demographic Update Tool
Contracted Enrollment Request
Provider Effective Date Policy
Definition of Enrollment, Credentialing, and Contracting
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 Pieces
Provider Orientation
Bulletins
QI Program
HEDIS
Practice Guidelines
Providing Quality Care
Coronavirus Information
Provider Claims Alerts
Become a Contracted Provider
MI Provider Credentialing Application (PDF)
MI Facility Credentialing Application (PDF)
MI Meridian Physian 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
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?
*
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:
Please complete the captcha by selecting the checkbox, I am not a robot.
Last Updated: 08/17/2023