Join Our Illinois Provider Network | Ambetter of Illinois

Thank you for your interest in participating in the Ambetter of Illinois network! If you would like to receive more information on becoming a provider within our network or would like to receive a contract, please contact us or call 1-855-745-5507.

Note: Completion of this form does not guarantee inclusion into the provider network. It generally takes 20 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 contact the Contracting Department at ILJoinOurNetwork@CENTENE.COM.

Step 1 - Provider Type

Select your provider type. **

Ancillary Clinic FQHC Group Practice Hospital Individual Provider RHC

Step 2 - Product Interest

Select the products you want to participate in.*

Meridian Medicaid Plan and YouthCare Meridian Medicare-Medicaid Plan Ambetter Wellcare

Step 3 - National Identifiers

Group NPI *

Tax ID Number * *

Step 4 - Illinois Medicaid Number

If applicable to your Product Interest, log into your IMPACT account to verify that your Illinois Medicaid Number is active. If your Illinois Medicaid Number is NOT active, this will result in a denied application for participation in Medicaid products.

Illinois Medicaid Number *

Please verify below that your Illinois Medicaid Number is currently active.

If your Illinois Medicaid Number is NOT active, this will result in a denied application for participation.

I verify that my Illinois Medicaid Number is currently active.

If applicable to your Product Interest, provide your Medicare Identifier (Medicare ID)

If your Medicare Identifier is NOT active, this will result in a denied application for participation in Medicare products.

Step 5 - Practice Contact Information

Practice Name *

City *

State *

Zip Code *

County *

Primary Phone Number *

Step 6 - Practice Information

Applying as:*

Specialist Primary Care Provider Other

Is this your primary specialty?*

yes no

Step 7 - Credentialing Contact Information

Name *

Phone *

Fax *

Email *

Please upload your completed W9 form.

Join Our Illinois Provider Network | Ambetter of Illinois

Join Our Network