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Provider Intake Form

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 internalcontracting@centene.com

Authorization is required if you need to treat a YouthCare Health 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.

Step 1 - Provider Type

Step 2 - Product Interest

Select the products you want to participate in.*

Step 3 - National Identifiers

Step 4 - Illinois Medicaid Number

Log into your IMPACT account to verify your Illinois Medicaid Number is active. If your Illinois Medicaid Number is NOT active, this will result in a denied application for participation.

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.

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

Step 5 - Practice Contact Information

Step 6 - Practice Information

To select multiple hospitals, hold down the "Ctrl" button when making your selections.

Step 7 - Credentialing Contact Information