Forms and Resources

Thank you for your interest in participating with Magnolia.

If you are a contracted Provider requesting to enroll a new Practitioner and/or a new location or group NPI under your existing contract, complete the following documents and email to MagnoliaCredentialing@centene.com for MSCAN, CHIP and Ambetter and MSProviderUpdates@centene.com for WellCare:

·       Provider Data Form (for Practitioners) 

·        Hospital/Ancillary Application (for Provider locations) 

*If you select multiple lines of business, you will be required to complete Magnolia’s Credentialing Application Magnolia Credentialing Application Packet

If you are a Non-contracted, Provider, you may request a contract by completing the form at the link provided below and refer to our Become a Provider page (Magnolia Health Medicaid Provider Application | Magnolia Health).

Contract Request Form 

• Care Management Referrals (PDF)
• Provider Care Management / Disease Management Referral Form (PDF)

• Claim Appeal Form (PDF)
• Claim Reconsideration Form (PDF)
• Claims FAQs (PDF)
• PaySpan (PDF)
• Taxonomy Code Billing Requirement (PDF)

• Discharge Consultation Documentation Form (PDF)
• Provider Notification of Pregnancy Form (PDF)

Dental Sedation Scoring Tool (PDF)

• EPSDT Brochure - Age 0-2 Years (PDF)
• EPSDT Brochure - Age 0-6 Years (PDF)
• EPSDT Brochure - Age 3-8 Years (PDF)
• EPSDT Brochure - Age 9-13 Years (PDF)
• EPSDT Brochure - Age 14-20 Years (PDF)
• EPSDT Brochure - Age 7-21 Years (PDF)

• Member Appeals Authorized Representative Form (PDF)

• Adult Wellness Visit Checklist (PDF)
• Connections Referral Form (PDF)
• Foster Care Health Information Form (PDF)
• Primary Care Provider (PCP) Change Form (PDF)
• Interpreter Request Form (PDF)

• Pharmacy Reimbursement
• Preferred Drug List (PDL)
• Division of Medicaid Preferred Drug List Changes
• Prior Authorization Forms

• Prior Authorization List (PDF)
• Inpatient Prior Authorization Form (PDF)
• Outpatient Prior Authorization Form (PDF)
• Supplemental Prior Authorization Form (PDF)
• Prior Authorization Tips - Urgent Requests
• Prior Authorization Tips - Timeliness of Prior Authorization Requests
• Prior Authorization Tips - Doctor's Orders
• Prior Authorization Tips - Do Not Use Copies of Old PA Forms
• Prior Authorization Tips - How to Fill Out the PA Form
• Prior Authorization Tips - Removal of PA for Observation, CPAP and BiPAP
• RADMD Resources

Magnolia Health offers an electronic, fillable form for providers to request a Physician-to-Physician Peer-to-Peer discussion regarding medical necessity determinations. This process allows the requesting provider to speak directly with a Magnolia Health Medical Director to review a denied service or treatment.

Peer-to-Peer Form

• 2026 Magnolia Health MississippiCAN Provider Manual (PDF)
• 2026 Magnolia Health CHIP Provider Manual (PDF)
• Centene Dental Provider Manual (PDF)
• Centene Vision Provider Manual (PDF)

• Provider Standards for Appointment Scheduling (PDF)

For Wellcare information, please visit our Wellcare website.

For Ambetter information, please visit our Ambetter website.