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Ready to renew your Medicaid coverage? Explore our step-by-step guide to Medicaid renewal. Here's how
Ready to renew your Medicaid coverage? Explore our step-by-step guide to Medicaid renewal. Here's how

Demographic Change

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Service Location Address

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Practitioner Current Name

Practitioner New Name

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Practitioner Name

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Practitioner Name

Service Location Address

New Provider Office Hours

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Service Location Address

Service Location Office Hours

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*If submitting for multiple products, please indicate applicable products in the comment section.*

If submitting for specific WellCare product(s), indicate applicable products in Comments section

If multiple practitioners' provider updates are needed, please download the Meridian Roster Template and attach it in the upload field. All roster fields are required.

Meridian Roster Template (Excel)
(Roster template revised 02/04/2022)

1. Providers must be IMPACT approved for any Medicaid, YouthCare, or Dual product, and Medicaid numbers must be supplied

2. Prior to Ambetter and Medicare submissions:

  • Validate CAQH is current and accessible to the health plan for all practitioners
  • NOTE: CMS does not allow more than 20 locations per practitioner

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