Documents and Forms

DOCUMENTS AND FORMS

DOCUMENTS AND FORMS

QUICKLINKS


 

Medical Referrals & Authorizations

Authorization Referral Form

Acknowledgment of Hysterectomy Form

Bariatric Surgery Checklist

Behavioral Health Discharge Transition of Care Form

Care Coordination/Complex Case Management Referral Form

Consent to Sterilization Form

Data Exchange Request Form

Electronic Medical Request Form

HealthHelp and eviCore Provider Notification

MeridianHealth - Illinois Prior Authorization Requirements

Mobile Crisis Response FAQs

Mobile Crisis Response Provider Reference Guide

Primary Care Provider Reassignment Form

Weight Watchers® Form

Weight Watchers® Exhausted Benefit Form

Pharmacy

Formulary Exception Form

Medication Prior Authorization Request Form

Member Request for Reimbursement Form

Online Pharmacy Prior Authorization (PA)

 

For additional pharmacy information, click here.

Billing

FORM144 IL Crossover Claim Resolution

Billing Guidelines for EAPG Pricing

C32 Provider Billing Education Guidance

CMHC Billing Guidelines

D01 Duplicate Claim Submissions Guidance

DASA Billing Guidelines

Electronic Funds Transfer Form

Encounter Billing Education

Encounter Clinic Billing FAQs

Guidelines for Custodial and Supportive Living Authorizations

HFS Managed Care Billing and Encounter Guidelines - DASA

Hospice Routine Home Care and Continuous Home Care

IAMHP Comprehensive Billing Manual

IAMHP Memo to All Health Plans

Illinois Medicaid Fee Schedule

LTC Billing Guidelines

Medical Assistance Program (MAP) Guidelines

MTM Transportation Billing Guidelines Review

Patient Credit File

Pharmaceutical Labelers with Signed Rebate Agreements

Physician Assistant Billing Guidelines

Renal Dialysis Value Code Requirements

▤  Request for Provider Dispute Form

Timely Submission of Encounter Data by Medicare-Medicaid Plans (MMPs) to CMS

IL APL Notice

Mandatory Training Attestation

Mandatory Training Attestation

Provider Medical Assistance Program Enrollment Forms

Agreement for Participation in MAP

Instructions for Enrollment into MAP

MAP Provider Enrollment Form

Mental Health Professionals Medical Assistance Program Enrollment Forms (LCPC, LMFT, MSW, etc.)

Mental Health Provider Enrollment Application

Mental Health Provider Instructions for MAP Enrollment

Preventive Care (HEDIS®)

Adolescent Immunization Exclusion Form

Adolescent Immunization Schedule

Adult Immunization Schedule

Asthma Exclusion Form

Breast Cancer Screening Exclusion Form

Cervical Cancer Screening Exclusion Form

Child Immunization Exclusion Form

Diabetes Exclusion Form

Follow-Up After Hospitalization for Mental Illness (FUH)

Healthy Rewards Program

Healthy Rewards Program Form

HEDIS® Criteria

HPV Exclusion Form

Partnership for Quality (P4Q Program)

Pediatric Immunization Schedule

Vision Benefits

MeridianHealth offers vision benefits to members enrolled in specific health plans.

Click here to view a chart summarizing the vision benefits available to members in each of our Illinois health plans.

 

Instructions – Ordering Vision Hardware from Classic Optical Laboratories (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

Instructions – Ordering Vision Hardware from JAK Optical Laboratories (for Medicaid and Medicare-Medicaid Alignment Initiative (MMAI) members)

  • NOTE: Please DO NOT contact JAK about any prior authorizations

Order Form – JAK Optical Laboratories

Credentialing and Roster Update

CAQH Credentialing Application

Illinois Credentialing Application

Universal Roster

EPSDT Forms

1 to 4 Weeks

2 Month

4 Month

6 Month

9 Month

12 Month

15 Month

18 Month

2 Year

3 Year

4 Year

5 Year

6 Year

7-8 Year

9-10 Year

11-17 Year

Recommendations for Preventive Pediatric Health Care

Regulatory Requirements Manual

Illinois Regulatory Requirements Manual

Michigan Regulatory Requirements Manual

Ohio Regulatory Requirements Manual

Subcontractor Regulatory Requirements Manual

Illinois Subcontractor Regulatory Requirements Manual

Advance Directives

Meridian's Advance Directives Information

Directivas Anticipadas información de Meridian

Living Will

Power of Attorney for Health Care
Resources for Illinois Advance Directives
Testamento Vital

State of Illinois Resources

Illinois Client Enrollment Services
Illinois Dept of Healthcare and Family Services
Medicare Provider- Supplier Enrollment

Critical Incidents

Critical Incident Form

HFS Critical Incident Guide

IL Reporting Grid

Page Last Modified: 4/5/2022 2:50:09 PM